Domiciliary midwifery and maternity bed needs

CHAPTER I

PREFACE

1. At their meeting on 29th June 1967 the Minister of Health’s Standing
Maternity and Midwifery Advisory Committee considered papers prepared by
the Department* on the future of the domiciliary midwifery service and on bed
needs for maternity patients. The former paper drew the attention of the Com-
mittee to certain aspects of the domiciliary midwifery service in the context of an
increasing hospital confinement rate, a shorter length of hospital stay and the
falling birth rate; and in a covering Note the Department sought the advice of
the Committee on the future of the local health authority domiciliary midwifery
service in the changing situation, having particular regard to the supervision of
midwives, the employment of domiciliary midwives in hospitals, the practica-
bility of a domiciliary service run by hospitals, and the care of the neonate.

2. The Committee took the view that the question of bed needs for maternity
patients was closely related to the other question on which their advice had been
sought and that neither could be considered in isolation. Accordingly they
decided that a Sub-Committee should be set up to look into both problems.

3. The Sub-Committee had their first meeting, at which Sir John Peel was
elected Chairman, on 6th September 1967, when they accepted the following
terms of reference:

“To consider the future of the domiciliary midwifery service and the
question of bed needs for maternity patients and to make recommenda-
tions.”

4. The Joint Secretaries of the Sub-Committee were Dr. Margaret M. Bates and
Mr. R. L. Gordon. Meetings were attended by various officers of the Department ;
by Dr. Elspeth Warwick of the Scottish Home and Health Department, Dr. Mary
Jenkins of the Welsh Office, and by Mr. J. S. Tomkinson and Professor J. P. M.
Tizard.

5. The Sub-Committee has met 13 times. Written evidence has been received, in
response to questionnaires, from Medical Officers of Health, Chairmen of Local
Medical Committees, the Central Midwives Board and the Senior Administra-
tive Medical Officers of Regional Hospital Boards, who also collated evidence
received from the Secretaries of Boards of Governors within their Regions, and
the Department has produced statistical papers at our request. These and other
papers received are considered in Chapter VIII . The Sub-Committee wish to
thank the British Medical Association for their co-operation in analysing and
summarising the evidence received from Chairmen of Local Medical Commit-
tees.

*In this report, ‘the Department’ refers to the Department of Health and Social Security,
Health service duties and functions in Wales passed to the Secretary of State for Wales on
1 April 1969, while the Sub-Committee were still considering evidence.

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CHAPTER II

INTRODUCTION

6 , The next following chapter reviews in some detail the developments in the
maternity services both before and since the Report of the Maternity Services
Committee (hereinafter referred to as the Cranbrook Committee) in 1959. The
Sub-Committee have, however, been aware that changes necessary, or already
evident, in the field of maternity services cannot be isolated from other more
general changes in the health services as a whole* Some of these relevant, but
more general, trends and developments are briefly considered in the following
paragraphs.

/ . Within general practice the tendency towards group working is accelerating,
j J group practices in their turn afford opportunities for specialisation which
were denied to the single handed practitioner and difficult to achieve even by
doctors working in partnership. Added to this, the last year or two has seen an
upsurge in the planning and building of health centres. Both these developments
aie likely to continue and may be seen as offering to general practitioners an
opportunity to reconsider the part they should play in the provision of maternity
services, we are aware that experiments in this field have already met with some
success.

8. Concurrently with the trend towards group practices there has been steady
progress in the development of schemes of attachment of local health authority
nursing sta.fi to general practices. Following the issue by the Department of
Health and Social Security of Circular 13/69 this progress may well be acceler-
ated. It has, however, been worthy of note that of the three local health authority
services, health visiting, home nursing and domiciliary midwifery, the last has
lagged far behind the other two in this development, and the possibility that mid-
wifery does not so readily lend itself to this form of organisation cannot be
discounted.

9. In the hospital and specialist services plans are going ahead for the provision
of district general hospitals which will provide the focal points hitherto lacking,
and the concentration of services which this concept implies must have a radical
effect upon the diffuse geographical distribution of the present hospital maternity
services. Quite apart from those aspects of existing small maternity units with
which the Sub-Committee are directly concerned, it is clear that the maternity
services of the future will be affected by the rationalisation already under way.

10. Overriding developments within the existing tripartite structure of the health
service, the Green Paper issued by the Minister of Health in 1968 has given rise
to wide discussion of possible future changes in the administrative structure of
the service as a whole. The Sub-Committee have taken the view that the broad
administrative structure is outside their terms of reference, and that their con-
cern with the ways in which maternity services are provided need not be

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influenced by possible structural changes. They are confident that their recom-
mendations may be seen as compatible with any administrative changes which
are likely to take place.

11. The Sub-Committee have also had in mind the possible implications of the
Seebohm Report and the Report of the Royal Commission on Local Govern-
ment in England. As to the former, the direct effect upon the maternity services
of the Seebohm Committee’s recommendations is thought to be minimal; less
directly, a reduction and concentration of the functions of health departments of
local health authorities might seem to offer an opportunity to review midwifery
provision within the existing framework, but it is unlikely that such a course, in
isolation, would contribute usefully to the solution of the main problems. It is
not thought that the recommendations of the Royal Commission are inconsist-
ent with the sorts of proposal the Sub-Committee have to offer.

12. Another development which could have a direct bearing upon the way in
which domiciliary midwives are at present employed is the Secretary of State’s
consideration of the implications of the Salmon Committee’s recommendations
for local authorities following the recommendations by the National Board for
Prices and Incomes (a) that the pay of local authority nursing staff should remain
linked with that of hospital nursing staff, and (b) that “Salmon” proposals
should be implemented as soon as possible. A Working Party is currently con-
sidering this question and is expected to report this year.

13. Since the Sub-Committee was set up the Joint Working Party on the Organ-
isation of Medical Work in Hospitals has issued its First Report, in which the
grouping of obstetrics and gynaecology within a “Division” is suggested.

14. Since the Sub-Committee began its work, the Abortion Act 1967 has become
law. The Act lays down that except in an emergency, an abortion must be carried
out in a National Health Service hospital, in an approved Services hospital or in
a place for the time being approved by the Secretary of State for the purpose of
the Act. The regulations governing notification under the Abortion Act require
each abortion to be notified to the Chief Medical Officer under conditions of
strict confidentiality. The number of abortions notified in England and Wales
during the first year after the Act came into force was 37,736 but it is still too
early to assess its effect on hospital bed requirements.

15. Another piece of legislation with implications for the future of the maternity
services was the National Health Service (Family Planning) Act 1967. This
enables local health authorities in England and Wales to provide a family plan-
ning service for all persons needing it, on non-medical as well as medical grounds,
either directly or through the agency of a voluntary body. General practitioners
in the National Health Service may also give a family planning service com-
prising advice and examination as part of general medical services, and hospitals
may provide a family planning service for patients requiring it on medical
grounds only. Recent studies at home and abroad have shown the value of a
hospital based family planning service particularly following delivery and after
abortions. An increasing number of medical schools provide teaching in control
of fertility and family planning techniques, reference to the need for which was
made in the Report of the Royal Commission on Medical Education.

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16. Finally, amendment of the law affecting the duties of local health authorities
with regard to the provision of midwifery services was contained in Section 10 of
the Health Services and Public Health Act 1968. The effect of the relevant pro-
visions was to enable local health authorities (a) to arrange for home nurses or
health visitors to visit to provide services during the “lying-in period” other than
those for which attendance by a midwife is requisite; (b) to make arrangements
with hospital authorities for local authority midwives to provide services in
hospitals; (c) to make arrangements for their midwives to work in the areas of
other local health authorities; and (d) to provide midwifery services other than
in the homes of patients.

17. Most of the matters mentioned above are relevant to the more detailed dis-
cussion of the problems, and their possible solutions, contained in later chapters
of this Report. Their statement here may serve to set a scene within which the
maternity services are part of a rapidly changing total service, one of the
dominant features of which is the logical move towards closer integration.

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CHAPTER III

BACKGROUND INFORMATION AND STATISTICS

18. The history of the practice of midwifery and obstetrics in this country from
their early beginnings, and their gradual evolution as skilled professions regu-
lated by responsible bodies and by successive Acts of Parliament is well known,
and need not be repeated here. The provision of maternity services has been
extended by successive legislation culminating in the National Health Service
Act of 1946 which secured for the first time the availability of complete maternity
care for all women. Services concerned with antenatal and postnatal care and
delivery, in common with other health services, then became shared between
general practitioners, hospitals and local health authorities, and a variety of
patterns of care developed, according to local circumstances. The resulting
tripartite administration has proved a difficult framework for the efficient
administration of maternity services.

19. The Committee of Enquiry into the Cost of the National Health Service
under the Chairmanship of Mr. C. W. Guillebaud, which presented its Report in
November 1955, recommended that the organisation of the maternity services
under the National Health Service should be reviewed at an early date. Para-
graphs 631 and 632 of the Report of the Guillebaud Committee stated:

“631. Many of our witnesses have told us that the division of the health
services into three branches has had its most serious impact on the maternity
and child welfare services. Responsibility for providing these services is now
divided between the hospital authorities, local Executive Councils and local
health authorities as follows:

(i) The hospital authorities are responsible for the provision of hospital
maternity beds and out-patient antenatal and postnatal treatment in
teaching and non-teaching hospitals.

(ii) The local health authorities are responsible for the provision of a
domiciliary midwifery service and antenatal and postnatal clinics.

(iii) The Executive Councils are responsible for making contracts with
general practitioners who undertake to provide maternity medical
services. These services involve the provision of prescribed antenatal
and postnatal care, with attendance at the confinement if necessary or
if the doctor desires to be present.

A general practitioner obstetrician (i.e. a general practitioner who
has been admitted to the obstetric list) may provide maternity medical
services to any expectant mother; but a doctor not on the obstetric list
may provide such services only for a woman on his own list.

(iv) The position is further complicated by the arrangements for providing
emergency medical aid for practising midwives. If a doctor is called by

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a midwife to an emergency under the medical aid scheme (i.e. to the
confinement of a woman for whom he has not undertaken to provide
maternity medical services) the doctor’s fees are paid by the local health
authority and not by the Executive Council.

632. Even within this general division of responsibility, there appear to be
wide variations in the way the services are now being provided between one
local authority’s area and another. In some areas, the antenatal clinics are
still manned by medical officers of the local authority, even though many of
the expectant mothers attending the clinics may have booked a general
practitioner to provide them with maternity medical services. In other areas,
the medical services at the clinics are provided by general practitioners em-
ployed by the local health authority on a sessional basis. In others, the
clinics may have ceased to provide a medical service at all, and are concen-
trating increasingly on the development of the educational aspects of
antenatal care, i.e., mothercraft (and even fathercraft), diet, hygiene, relaxa-
tion exercises, etc. Or again, the general practitioners may be providing
‘clinic sessions’ in their own surgeries, with the local authority midwives in
attendance.”

20. As a direct result of the recommendation for a review the Cranbrook Com-
mittee was set up in 1956 and produced its report in 1959. Paragraphs 10-16 of
the Report of the Cranbrook Committee stated:

“10. During our deliberations we have borne in mind these comments of
the Guillebaud Committee. Perhaps we should say at this early stage of our
Report that the evidence we received did not suggest that the maternity
services were in a serious state of confusion; neither would we be inclined to
say that the tripartite structure of the health services has of itself proved
more detrimental to the efficiency of the maternity services than to that of
the other branches of the health service.

11. Were it a question of reconstructing the personal health services as a
whole, closely associated as they are with the work of the general practition-
ers and the hospitals, in the light of experience gained during the ten years
since 1948, it is probable that the majority of us would suggest that a unified
service, including of course a maternity service under the control of one
authority, might be a desirable arrangement. Our deliberations have con-
vinced us, however, that to suggest, at this stage, any drastic re-organisation
of the maternity services alone, so as to place them under the sole control of
either the hospital authorities, the local health authorities or of some quite
new body, would be to create more problems than it would solve.

12. If we accept, as we are satisfied we must, that confinements will continue
to take place both in hospitals and at home and that the existing tripartite
system of administration must continue for some time to come, the real
problem crystallises into one of co-operation and co-ordination between the
individuals providing the various maternity services.

13. We believe that what is required at present is the retention of the
existing tripartite structure of the maternity services but with a clearer
definition of the responsibilities of the respective bodies providing the
different parts of the service and the development— which should then
become easier to achieve — of co-ordination and co-operation between them.

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14. Our terms of reference include an assessment of the content of the
maternity services and we have discussed this in some detail in our Report.
In particular, in Chapter 4, we have outlined for the benefit of the lay
reader, what we think should be the characteristics of a good maternity
service of which we consider a very high standard of antenatal care is per-
haps the most important.

15. We have come to the conclusion that under present day conditions the
practice of obstetrics requires the exercise of special skill beyond the normal
competence of the general practitioner and a degree of experience that, with
the present high institutional confinement rate, the average family doctor
is unlikely to be able to maintain. We have therefore recommended the
retention of an obstetric list and more uniform criteria which should be
applied for admission to the list or retention on it.

16. Furthermore we have suggested that provision should be made over the
country as a whole of a sufficient number of maternity beds to allow of an
average of 70 per cent institutional confinements, with the assumption that
the normal period of stay in hospital after delivery will be ten days. We
explain in our Report why we have come to these conclusions and indicate
certain ways in which co-ordination can be developed.”.

These expressed the views of the Cranbrook Committee and set the pattern for
the development of the maternity services for the next decade. For the past few
years, however, there has been growing awareness that a further review of the
maternity services was due.

21. Table 1 (page 67) shows that the live birth rate rose from 15 per 1,000 in 1955
to 18 ’5 per 1,000 in 1964, but has since declined to 16-9 in 1968. In the period
1955-1965 all births increased by nearly 30 per cent. During this period the
number of births in National Health Service hospitals rose by almost 50 per cent.
The hospital confinement rate rose from 60 per cent reaching the Cranbrook
target figure of 70 per cent in 1965, and by 1967 had reached 75 per cent. The
total institutional (i.e. other than domiciliary) confinement rate reached 80-8 per
cent in 1968. By contrast the number of maternity beds increased by only 15 per
cent in the same period, and the increasing hospital confinement rate was
achieved mainly by shortening the length of stay,

22. Table 2 (page 67) shows that the average total length of stay in National
Health Service hospitals fell over 13 years from 12T days to 8*0 days in con-
sultant units, and from 11*1 days to 6*8 days in general practitioner units. Early
discharge within 48 hours from hospital was resorted to in some areas to over-
come the shortage of maternity beds, and enable all women in the vulnerable
categories to be admitted. The Ministry of Health issued guidance on the plan-
ning of early discharge schemes in Circular 6/65 and HM(65)32.

23. Table 3 (page 67) demonstrates the main changes in postnatal stay in
National Health Service hospitals, distinguishing booked and unbooked cases,
for 1958 to 1968. The percentage of women with postnatal stay in hospital of 2
days or less was 4*9 per cent in 1958 compared with 14*4 per cent in 1968.

24. The provision of maternity services throughout the country is not uniform.
Although a 78*6 per cent hospital confinement rate and a 80*6 per cent institu-
tional confinement rate was achieved nationally in 1968 there is marked regional

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variation. Table 4 (page 68) compares institutional confinement rates in local
health, authorities grouped into hospital regions for 1967 and 1968 and shows
that the number of authorities achieving a rate of 80 per cent or over increased
from 86 to 110, while the number with a rate of 60 per cent or below fell from 3
to 1.

25. The rising hospital confinement rate has had the following effects on the
midwifery service:

(a) National figures show that domiciliary midwives are becoming less con-
cerned with patients in labour and increasingly occupied with the
postnatal nursing of patients discharged early from hospital.

(b) This reduction in domiciliary deliveries in some areas has made it diffi-
cult to secure sufficient clinical experience for pupil midwives conducting
cases on the district. (The Central Midwives Board have made some con-
cessions about the required number of cases.)

(c) Experimental schemes have been tried in different parts of the country
whereby domiciliary midwives have delivered their patients in general
practitioner beds and then following an early discharge, have continued
their postnatal care at home. This procedure has now been regularized
under the provisions of the Health Services and Public Health Act 1968.

(d) The process of attachment of local authority nursing staff to general
practices is proceeding rapidly. By early 1967, 17 per cent of health
visitors were so attached. There has been a steady though smaller develop-
ment in the attachment of domiciliary midwives to one or more group
practices in local health authority areas. In 1964, 2 per cent, and in
December 1966, 8 per cent of all domiciliary midwives were attached in
this way. Such attachments have shown the value of doctors, midwives,
and health visitors working together as a team. This sharing of care has
been much appreciated by the mothers.

( e ) In certain areas with a very high hospital confinement rate, the cost of
maintaining an efficient domiciliary service has become uneconomic.

26. Recent developments have tended to increase the general practitioners*
participation in hospital and community services:

(a) Attachment schemes involving local health authority domiciliary mid-
wives have already been mentioned.

( b ) There is a trend towards practice from health centre premises, providing
a further link with community services.

(c) Growing numbers of group practices are evolving in which one or two
members of the group specialize in midwifery and provide this service
for all the maternity patients of the practice,

(d) General practitioners are replacing local health authority medical
officers in staffing the maternity and child health climes. In particular
they are providing the ante and postnatal care for their own patients or
for the patients of the group practice.

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(e) There were 23,035 maternity beds, including 4,882 general practitioner
maternity beds, allocated in 1968 which was a net increase of 2*1 per cent
over the previous year. General practitioner beds make up about 21 per
cent of all maternity beds. Since 1955 the number of general practitioner
maternity beds has increased by 82-8 per cent compared with 4*3 per
cent for consultant beds.

(f) New hospitals are being built incorporating general practitioner beds as
part of a fully equipped and staffed maternity unit. The building of
district general hospitals will continue this policy.

27. In addition to these changes, there have been difficulties in implementing the
Cranbrook recommendation to maintain a good domiciliary maternity service.
Despite detailed guidance the proper selection of women who are suitable for
delivery in their own homes has not been fully achieved. The Perinatal Mortality
Survey (Butler and Bonham 1963) gave evidence of poor selection for home
delivery. The Survey showed that in 1958 almost one in four women expecting
their first babies and booked for home deliveries had to be admitted to hospital
late in pregnancy or during labour. The perinatal mortality rate for these infants
of mothers booked for home confinement but transferred to consultant units in
late pregnancy or during labour was shown to be three times the national survey
average.

28. The North West Metropolitan Regional Hospital Board’s Obstetric Survey
1962-1964 (Law 1967) studied in detail four of the high risk groups of mothers
identified in the Perinatal Mortality Survey (see paragraph 87) and recommended
that all cases in the four high risk groups should be delivered in hospital, with the
possible exception of certain selected grand multiparae. Successive Reports of
the Confidential Enquiries into Maternal Deaths have also commented on the
importance of proper booking.

29. Table 5 (page 68) shows the changes in maternal and perinatal mortality and
in hospital and institutional confinement rates since 1955.

30. Instead of recommending that the tripartite structure of the maternity
service should be modified, the Cranbrook Committee considered that better
methods of co-ordination and co-operation were needed. This was thought to be
of such importance that a general pattern of co-ordination was suggested which
was capable of being adapted to local circumstances:

* ‘ Chapter 1 1 . Co-ordination Arrangements.

380. Local maternity liaison committees with a professional membership
should be formed to ensure that local provisions for maternity care are
utilised to the best advantage. (Paragraphs 310 and 311).

381. Local clinical meetings should be encouraged so that all persons in an
area responsible for carrying out maternity care can discuss the clinical
aspects of maternity cases. (Paragraph 314).

382. The publication of clinical reports by the hospital authorities, should
be encouraged and, with the co-operation of the local authorities, extended
to cover the domiciliary midwifery service. (Paragraph 315).

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383. A standard co-operation card should be provided for use on a national
basis. (Paragraph 316).

384. Arrangements for the exchange of information between the various
individuals carrying out maternity care need to be strengthened and we have
indicated in paragraphs 319 and 324 and in Appendix VIII the arrangements
which should be adopted. (Paragraphs 319 to 324).”

These measures have been implemented with varying degrees of success.
Existing arrangements for the exchange of information are cumbersome and
time-consuming, and in practice it has been found impossible to reach agreement
on the use of a standard co-operation card. The value of maternity liaison com-
mittees is said to be often hampered by lack of executive function.

31. In a number of the highly developed countries of the world, including those
of Western Europe, North America, Russia, and Eastern Europe, hospital con-
finement for all mothers has become the established practice. The trend in
Britain is towards this, but the reason that complete hospital confinement has
not been achieved has been partly due to tradition and partly to limited re-
sources within the National Health Service. International comparisons of the
maternity bed ratio per 1,000 population and the related birth rates and average
duration of stay in hospital (latest available comparable figures) are shown in
Table 6 (page 69).

32. Table 7 (page 69) gives information from the Government Actuary’s Depart-
ment based on mid-1968 population data and anticipates a rising birth rate.
Future estimates indicate that by 1971 the number of births will almost have
reached the 1964 peak and will continue to increase. The possible effects on the
birth rate of changing social and economic conditions and of the Family Plan-
ning Act 1967 and the Abortion Act 1967 are unpredictable.

33. The advantages and disadvantages of home and hospital confinements were
discussed in the Cranbrook Report. The main argument, which hinges on the
safety of hospital delivery on the one hand and the emotional security for the
patient and her other children in home delivery on the other, is not easily re-
solved. The compromise of hospital delivery, followed by early discharge home
with suitable supporting care, is a method which has been developing over the
last few years and appears to be gaining favour with mothers.

34. There is a need to consider the best deployment of skilled staff. There is
some difficulty in staffing maternity units with midwives and the distribution of
consultants and other medical staff is uneven.

35. Many of the strictures of the Guillebaud Report on the overlapping of
maternity services are still relevant. One of the main difficulties from the point of
view of the patient’s safety is in the transfer of records and communication
generally between her different advisers.

36. There are marked regional differences in social conditions, and this is re-
flected in the perinatal mortality figures in Table 8 (page 70). A further difficulty
is posed by the differing needs of rural communities and the long distances
involved in travelling to and from centralised hospitals.

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CHAPTER IV

MATERNITY SERVICES PROVIDED BY MIDWIVES

37. As mentioned in Chapter III, it is not proposed to repeat the full historical
review of the development of midwifery as a skilled profession provided in the
Cranbrook Report. This Chapter will concern itself mainly with those aspects of
midwifery in relation to which legislative and other changes during the past few
years have had significant effects.

38. Appendix B of the Report of the Work of the Central Midwives Board for
the year ended March 31st 1968 shows that during the twelve months ended
January 31st 1968 20,399 midwives in England and Wales notified their intention
to practise. The total number of midwives notifying their intention to practise
shown in Table 9 (page 70) fell between 1957 and I960, then rose until 1967, and
again fell in 1968.

39. Between 1959 and 1968 there has been an increase in the number of certified
midwives employed in both hospitals and the domiciliary service. The distribu-
tion between the two services is shown in Table 10 (page 71). A small number of
midwives practise elsewhere, e.g. the Central Midwives Board’s Report for the
year ended March 31st 1968 showed that 281 worked in nursing homes and 186
were practising independently. It also recorded that local health authorities
employed 375 midwives as non-medical supervisors or assistant supervisors of
midwives.

40. Between 1959 and 1968 there has been a considerable change in the pattern
of provision of midwifery services. The National Health Service hospital con-
finement rate has risen from 60-7 per cent to 78*6 per cent. The actual number of
births taking place in hospitals and at home is shown in Table 11 (page 72)
together with the number of patients delivered in hospitals and other institutions,
but discharged early and attended by domiciliary midwives.

41. Comparison of Tables 10 and 1 1 (pages 71 & 72) shows that while in National
Health Service hospitals there has been an increase in both deliveries and num-,
bers of midwives, in the domiciliary field the number of midwives, which de-
creased annually until 1963, has since then decreased only slightly in relation to
the number of domiciliary deliveries, which has fallen steadily each year since
1962. Domiciliary midwives have, however, been increasingly concerned with the
postnatal care of patients discharged early following delivery in hospital. Actual
numbers of whole-time staff in 1968 were 3,406 showing a decrease for the
second year in succession. Part-time staff numbered 3,608; on average they
worked 40 per cent of the hours of a whole-time midwife, and many of them were
also employed part-time on other nursing duties. Table 12 (page 73) shows the
distribution of domiciliary midwives employed by various types of local health
authority in 1968. Table 13 (page 73) gives a similar indication of the distribution
of administrative and supervisory staff.

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42. The age distribution of all midwives practising in the years 1965-1968 is
shown in Table 14 (page 73), taken from the Central Midwives Board’s Report
mentioned above. Over the three years there have been slight declines in the
under 29 and 50-59 age group percentages, and a rise in the percentage of
practising midwives between 30 and 49 years of age. These trends are too slight
to be conclusive, but may reflect some fall in recruitment; there is little sign of
unusual wastage among established midwives.

43. While the basic function of the midwife has not changed, there has been
increasing recognition of her ability to extend her services beyond the provision
of attention at the time of actual delivery, and of her technical competence to
give total care to mother and child throughout pregnancy, labour and the
puerperium. The following definition of a midwife was agreed by the W. H. O.
Moscow Conference:

“A midwife is a person specially instructed and qualified to provide care for
women during pregnancy, delivery and the postnatal period, and for the
newly-born infant. This care includes preventative measures, health educa-
tion, the detection of abnormal conditions in mother and child, the procure-
ment of medical assistance and the execution of emergency measures in the
absence of medical help”.

This definition has been approved by the Central Midwives Board.

44. The recognition of the emotional needs of women by their attendants was
emphasised in the report of the Standing Maternity and Midwifery Advisory
Committee ‘Human Relations in Obstetrics, 1961’. The importance of the
proper attitudes and approach to confinement and parenthood by the patient
and her family was re-afiirmed by a study carried out by the Royal College of
Midwives, the report of which, ‘Preparation for Parenthood’, was published in
1966.

45. The midwife has continued to play a significant part in research since so
much depends on trained observation and careful record keeping of all the cir-
cumstances leading up to and associated with birth.

46. Within the last decade there have been some fundamental changes affecting
the organisation of midwives’ work. The most important of these have been :

(i) the rise in the hospital confinement rate and the corresponding increase
in early discharge, already mentioned above;

(ii) the development of experimental schemes whereby domiciliary mid-
wives deliver their patients in hospital ;

(iii) the attachment of domiciliary midwives to group practices, and the
corresponding development of the concept of the obstetric team.

47. The first of these changes has had widespread effects, further reference to
which will be made when we consider, in a later chapter, evidence received from
Medical Officers of Health. Circular 6/65 issued by the Ministry of Health
emphasised the importance of planned early discharges. Planning involves an
antenatal visit or visits by the domiciliary midwife to the patient’s home, and
discussion of the preparation necessary for the reception from hospital, soon
after delivery, of mother and newly born infant. The midwife advises and where
necessary calls on other resources in the health and welfare services to support or

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assist the patient and her family. Following the discharge of the mother and baby
from hospital the domiciliary midwife visits in the same way as if the confine-
ment had taken place at home, giving the detailed care and advice needed and
handing over to the health visitor when her services are no longer required. It is
hardly necessary to stress that co-ordination between local authority, general
medical and hospital services is essential when patients are discharged from
hospital, whether early or late.

48. The idea of a general practitioner maternity unit in which domiciliary mid-
wives could deliver their patients was put forward more than 10 years ago
(Sluglett and Walker 1956). The authors were prompted to suggest such a scheme
as a compromise between the rival claims of home or hospital as the best place
for a potentially normal confinement. They were also influenced by the fact that
in Bristol at that time, as in Britain generally, the trend towards hospital delivery
was already becoming established. The scheme was an attempt to combine the
advantages of both hospital safety and home care. The arrangements which the
paper outlined were essentially simple. It was suggested that the unit should con-
sist of a block of labour wards, attached to a maternity hospital, in which
patients would be delivered by their general practitioners and domiciliary mid-
wives and would then be returned to their homes within a few hours of delivery.
Since the publication of that paper the idea has gained ground and several
schemes based on the original suggestions, by which domiciliary midwives
deliver their patients in hospital, have developed. There were until 1968, however,
legal limitations to the employment of local health authority domiciliary mid-
wives elsewhere than in the patient’s own home. Section 10 of the Health
Services and Public Health Act 1968 which replaced and extended the provisions
of Section 23 of the National Health Service Act 1946 removed most of the
legal difficulties (Appendix A). Schemes of integration vary in nature throughout
the country. In Cardiff and Salford, for instance, the general practitioner
delivery units are arranged entirely for short stay, the patient being discharged
home within a few hours of delivery. Others are run on the lines of maternity
units where the patient stays for 48 hours, or longer if necessary for social
reasons. One 25 bedded general practitioner unit attached to a maternity hos-
pital opened in 1968 with a midwifery staff consisting entirely of domiciliary
midwives is administered by the non-medical supervisor of midwives of the city.
In addition to their duties in this unit the midwives care for patients confined in
their own homes as well as conducting antenatal and postnatal care in the home.

49. Present trends underline the importance of midwife and doctor working
closely together, whether in community or hospital, and co-ordinating with other
branches of the health and welfare services. In some areas schemes of attach-
ment to or liaison with group medical practices help the integration between
general practitioner and domiciliary midwifery services, giving better and more
continuous patient care. Such schemes may, however, be difficult to organise and
the attachment of domiciliary midwives is much less common at present than
that of health visitors or home nurses.

50. In some areas where patients for hospital confinement live a considerable
distance from the hospital, or where hospital antenatal clinic facilities are limited,
the antenatal care after the initial booking visit and up to approximately 30-34
weeks of pregnancy is undertaken by the general practitioner and the domiciliary
midwife.

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51. The Midwives Act 1951 requires the Central Midwives Board to make rules
regulating, and restricting within due limits, the practice of midwives, and pro-
vides that local supervising authorities should be responsible for general
supervision of that practice, no matter by whom the midwives are employed. No
changes have taken place in the statutory provisions since the Cranbrook Com-
mittee described the situation in 1957 in their Report, although we are aware
that the Royal College of Midwives and Central Midwives Board have expressed
a desire for revision of the regulations governing the supervision of midwives.
Circumstances have changed considerably since these regulations were made;
they are now out of date and need to be reconsidered. Further reference to super-
vision will be made later in this report when we come to consider the evidence
received by the Sub-Committee.

52. Courses of training for midwifery take place only at institutions approved by
the Central Midwives Board. The training of a pupil midwife comprises theoreti-
cal, practical and clinical instruction; attendance on, and the nursing care of
mothers and their new born infants. Emphasis is placed upon the midwife’s role
in health education and preparation for motherhood, including her understand-
ing of the emotional needs of women during pregnancy, labour and puerperium.

53. The course of midwifery training comprises two parts each followed by an
examination. For nurses on the general or sick children’s parts of the State
Register, Part I training lasts 6 months; for those having already taken obstetric
nurse training, four months ; for nurses on the psychiatric and fever parts of the
State Register, enrolled nurses, persons on the Register of the Chartered Society
of Physiotherapy who have passed the Final Examination for the Orthopaedic
Nursing Certificate and holders of the certificate of the British Tuberculosis
Association, 12 months; and for others, 18 months. Part II training lasts 6
months, of which at least 3 months must be spent in domiciliary practice where
the pupil will learn community care and during the whole course of her training
she must conduct a minimum of 30 deliveries.

54. The number of pupil midwives entering first period training schools during
the year ended March 31st 1968 showed, according to figures contained in the
Central Midwives Board’s Report, a decrease of 68 on the previous year’s figures,
and the number of pupils entering second period training schools decreased by
112. Of the 5,910 pupil midwives entering the first period training schools in
1967/68, 527 (8*9 per cent) were taking the 4 months course, 4,636 (78*4 per
cent) the 6 months course, 434 (7*3 per cent) the 12 months course and 313 (5*3
per cent) the 18 months course.

55. A joint statement by the General Nursing Council and Central Midwives
Board announced in 1960 that they had agreed in principle to the provision of a
period of obstetric nurse training for female student nurses during general train-
ing. A course of 12 weeks training in obstetric nursing enables a reduction of two
months to be made in subsequent midwifery training. At March 31st 1968, 152
hospitals, 140 of which had training schemes in operation, had been approved
jointly by the Central Midwives Board and the General Nursing Council as
obstetric nurse training schools. 1,449 student nurses were then undergoing
obstetric nurse training and since 1961 11,927 student nurses have completed
training, of whom 974 have qualified subsequently as midwives.

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56. The Central Midwives Board have a panel of educational supervisors who
visit all hospitals seeking approval to provide training and carry out a regular
programme of visits to all midwifery training schools. The Board approve resi-
dential and part-time courses of instruction for the midwife Teacher’s Diploma
Examination, and the refresher courses which midwives in practice are required
to attend in accordance with Section G of the Midwives Rules.

57. A working party set up by the Central Midwives Board to consider the future
development of midwifery training presented their Report to the Board in
October 1966. They recommended combining the present first and second parts
of midwifery training into an integrated scheme of training lasting a year with a
single examination for the S.C.M. certificate.

58. As a result of the Report of the Salmon Committee on Senior Nursing Staff
Structure in the hospital service new schemes based on the Committee’s findings
are being implemented in some areas. The aim of the Salmon recommendations
was to improve patient care by making the nursing and midwifery administration
more efficient, by improving its status in relation to hospital administration
generally, and by making the higher posts in the nursing and midwifery career
structure in hospitals more attractive and more satisfying. Under the new pro-
posals it is hoped that nurses and midwives will be better able to plan their
careers with the assurance that they will receive the appropriate training for each
new post and will thus be encouraged to take an active interest in management
and general administration of the nursing and midwifery services as a whole. The
Salmon Report recognised the need for all nurses and midwives involved in
administration, whether in the ward or in higher posts, to undergo some form of
management training, and recommended that immediately after gaining pro-
motion the nurse or midwife should be given appropriate training for her new
responsibilities. Similar needs exist in the domiciliary nursing and midwifery
services, and reference has already been made to the working party currently
undertaking a review of the domiciliary nursing services.

59. The report by a Sub-Committee of the Standing Nursing Advisory Com-
mittee, in 1968, on “Relieving Nurses of Non-Nursing Duties in General and
Maternity Hospitals” identified a wide range of duties commonly carried out by
nurses and midwives which do not require their particular skills. It discussed
methods of relieving nurses and midwives of such duties, and suggested that
ward housekeeping teams be introduced.

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CHAPTER Y

MATERNITY MEDICAL SERVICES PROVIDED BY
GENERAL PRACTITIONERS

60. An ontline of the administration existing in 1959 was given in the Cranbrook
Report. Changes which have occurred since then axe dealt with in the following
paragraphs, which will be concerned also with statistical trends and other
developments affecting general practitioner obstetricians.

61. Details of total numbers of general practitioners, and the numbers of
principal medical practitioners analysed by list size and regions are shown in
Tables 15 and 16 (pages 74 and 75).

62. In 1962 the Minister of Health in agreement with representatives of the
profession made changes in the wording of the definition of, and the terms of
service for, maternity medical services and in the system of fees. The revised
terms of service for the provision of maternity medical services are:

<i) In the case of maternity medical services the expression “all proper and
necessary treatment” shall comprise all necessary medical services
during pregnancy, confinement and the postnatal period including:

id) attendance at an emergency in connection with the pregnancy if the
practitioner is summoned on behalf of the patient;

(b) attendance if summoned by the midwife;

( c ) where the practitioner is not the practitioner in whose list the person
is included, the issue if required to the person or her personal repre-
sentative of certificates of pregnancy, expected confinement and
confinement.

(ii) All practitioners providing maternity medical services should have
regard to and be guided by modern authoritative medical opinion such
as the advice given by the Standing Maternity and Midwifery Advisory
Committee in the memorandum on medical care under the maternity
medical services.

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63. The current remuneration for maternity medical services provided by
general practitioners is as fallows:

Item

1

2

3 (a) and
(b)

5

6
?

General

General

Practitioner

Practitioner

on the

not on the

Obstetric List

Obstetric List

£ s. d.

£ s. d.

Complete maternity medical services

15 17 6

9 5 0

Complete antenatal care

9 5 0

5 8 0

Miscarriage

5 6 0

3 6 3

Other partial antenatal care, subject to an
overriding maximum of

6 12 0

3 17 0

(n) antenatal examinations, each

19 0

11 0

(b) obstetric emergencies, each attendance

1 6 6

15 6

Confinement

2 13 0

1 11 0

Complete postnatal care

3 19 6

2 16 9

Partial postnatal care, subject to an over-
riding maximum of

2 13 0

1 17 9

(a) each attendance

10 6

7 6

(b) full postnatal examination

1 6 6

19 0.

64. The proportion of part services in the maternity work done by general
practitioners has increased. In 1962 payment was made for complete services in
306,574 cases and part services in a further 338,264 including miscarriages. The
comparable figures for 1968 were 280,168 and 449,597. A number of doctors
whose names appear on the obstetric list may no longer take any important share
of obstetric work. The average of about 17 cases of complete service and about
27 cases of part service may, therefore be misleading. Table 17 (page 76) shows
that in 1968 3,161 complete services and 15,892 part services were given by
doctors not on the obstetric list.

65. Of the 397,442 part services (excluding miscarriages) given by all general
practitioners in 1968 110,964 or less than one-third were for partial antenatal
care without confinement and 150,083 or over one-third were for partial ante-
natal and partial postnatal care. These figures reflect the increasing extent to
which hospitals delegate to general practitioners some of the antenatal and post-
natal care of patients delivered in hospital.

66. It is of interest also that of the approximately 820,000 women confined in
1968 the general practitioner was concerned in the care of 677,610 or 83 per cent
of them.

67. The number of general practitioners on the obstetric list on 1st October 1968
was 16,407, or 77 per cent of all general practitioners.

68. There has. been an increase in the number of doctors awarded the Diploma
in Obstetrics of the Royal College of Obstetricians and Gynaecologists, which is
intended for general practitioners. It is not known with accuracy how many of
these doctors go into general practice. The report of the Working Party of the
Royal College of General Practitioners on Obstetrics in General Practice (1968)
estimated that about 50 per cent of new entrants to general practice will hold the
Diploma. This was based on a survey among 349 doctors in 1965 who had. taken
the Diploma in 1955, and it was assumed that the proportion of diplomates
entering general practice had not changed since 1955.

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69. A notice from the Ministry of Health to Executive Councils in December
1960 announced the intention of arranging for review by local obstetric com-
mittees, at the end of 5 years, of doctors whose names were included in the
obstetric list, in order to approve their retention.

70. In 1966 the Minister of Health in agreement with the representatives of the
profession reconsidered the conditions required by a doctor applying to the local
obstetric committee for inclusion in the list. Certain minor changes were intro-
duced, which were more in the nature of clarification. They did not apply to
doctors already included in the list. The conditions are set out in full in Appendix B.

71. The proposed review of general practitioner obstetricians, referred to above,
was postponed because of the “Charter Negotiations” which included a major
review of the whole framework of the general medical services.

72. Recent reports which have an important bearing on the general practitioner
obstetrician are considered later in this report. These were issued by the Royal
Commission on Medical Education, a Working Party on Obstetrics of the Royal
College of General Practitioners, and the Council of the Royal College of
Obstetricians and Gynaecologists.

73. We are aware that in view of these recent developments the question of
revising the obstetric list and the criteria for admission to and retention on it are
now being considered by the Department of Health and Social Security.

74. The number of domiciliary confinements attended by midwives under
National Health Service arrangements in 1968 was 156,880. The doctor was
booked in 153,120 or 98 per cent of confinements and was present at the delivery
in 33,279 or 22 per cent of such cases. Of the 3,760 or 2*4 per cent of domiciliary
confinements where a doctor was not booked a doctor was present at delivery in
574 or 15*2 per cent of such cases. About half (339,187) of all women, delivered
in hospital and other institutions who were discharged home before the tenth day
were attended by domiciliary midwives. Of the 187,556 registered legitimate
births which took place at home in 1967 9,341 were to mothers who had four or
more previous children and 13,000 were to women aged 35 years or more.

75. In 1968, 853 deliveries took place in mother and baby homes registered as
maternity homes. A doctor was present at some time during labour in 620 in-
stances. Unsupported mothers constitute a relatively small, but high risk group,
the majority of whom are delivered in hospital.

76. In 1968, 7,453 sessions were held by general practitioners employed on a
sessional basis to provide antenatal and postnatal care for local health authori-
ties. Sessions held on local health authority premises by general practitioners for
their own patients are not included in this figure. In 1965, 682 general prac-
titioners used local health authority premises during the year for antenatal and
postnatal sessions reserved for patients on their list. The Cranbrook Report
recommended that the general practitioner obstetrician should ultimately re-
place the local authority medical officer in providing maternity care in local
authority antenatal clinics, but in 1968, 31,845 antenatal and postnatal sessions
were held by medical officers of the local health authority and by medical
officers and midwives jointly.

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77. The Cranbrook Report recommended that all general practitioner obstetric-
ians should have access to general practitioner beds, and that these should be
within or very close to consultant maternity hospitals or general hospitals with
maternity departments. It also suggested that a consultant obstetrician should
have overall responsibility for supervision of general practitioner beds. These
objectives have not been reached on a national scale for various reasons. Accounts
of two experimental schemes based on these precepts (Oldershaw and Brudenell
1968 and Rhodes 1968) are given in Appendix C. These illustrate some of the
difficulties encountered in the setting up and running of such schemes. They also
suggest that these arrangements are of considerable benefit to the patients.

78. There is now considerable interest in and discussion among the profession on
the provision of general practitioner beds in hospital and opinion is moving
towards a closer association between general practitioner and consultant beds
wherever possible. A major difficulty lies in providing ready access to hospital
beds for all general practitioner obstetricians who wish to use them. Decisions
on clinical responsibility are not easily resolved but are of fundamental
importance. Evidence on these topics is examined in detail later.

79. The development of the maternity services has meant that several different
patterns of care are possible for patients, depending on individual and local
circumstances. Thus a general practitioner’s participation may range from con-
firmation of pregnancy and arranging for hospital booking at the initial visit, to
rendering complete maternity services throughout pregnancy, delivery, and the
puerperium. Between these two extremes, the practitioner may share his patient’s
care in varying degrees with local health authority midwives and hospital staff.

80. In the relatively few instances where local health authority midwives are
attached to practices, some continuity of care of patients booked for hospital
confinement is ensured, whereas a patient attending a hospital for antenatal care
may be seen by a succession of professional attendants. Recently, however, the
trend has been for hospitals to delegate more of the antenatal and postnatal care
of patients to their general practitioners. The disadvantages of divided respon-
sibility are perhaps of greatest importance during the period of antenatal
surveillance, when the exchange of information on the patient’s condition may
be vital.

81. The co-operation record card, introduced in recent years by the Ministry of
Health, was devised in an attempt to facilitate the passage of this information
between the patient’s professional attendants. If the patient carries this card, and
if it has been properly written up there should be no mishaps from lack of in-
formation. The report of the working party on Obstetrics in General Practice,
published by the Council of the Royal College of General Practitioners (1968)
considered the card to be of considerable value where several persons or agencies
were involved in the care of one patient, but pointed out that it had not been
universally adopted. They referred to frequent overlapping and duplication of
records, and thought that the general situation with regard to maternity records
was chaotic.

82. Co-operation record cards are found useful for the exchange of information
between general practitioner and midwife but are not sufficiently used by hospital
staff and are rarely returned to the family doctor. Unfortunately it has not been
possible to reach agreement nationally on the form of record card. The Council

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of the Royal College of Obstetricians and Gynaecologists in its report on
Hospital Obstetrics and the General Practitioner (1968) considered that in an
integrated maternity service in which general practitioner obstetricians were part
of the team, a single record system covering all cases delivered in the hospital,
would be essential.

83. The percentage distribution of the different arrangements for antenatal care
was studied by the Perinatal Mortality Survey of the National Birthday Trust
(Butler and Bonham 1963) with particular reference to mortality ratios. Table 18
(page 77) is taken from the Report. This shows that except for those with no
care, those seen solely by a general practitioner (11 T per cent) had the highest
perinatal mortality. Less than half the mothers in the survey began prenatal care
before the sixteenth week. Prenatal care began latest in high parity mothers of
whom only 29-3 per cent had presented themselves for examination at 16 weeks
gestation.

84. The importance of antenatal care to the outcome of pregnancy for both
mother and infant is generally acknowledged. Maternal mortality and perinatal
mortality rates are, therefore, to some extent a reflection of the quality of that
care. In this connection Table 19 (page 77) shows that although the overall
maternal mortality rate in England and Wales fell from 0*47 per 1,000 in 1957
to 0*20 per 1,000 in 1967, the actual number of deaths from toxaemia of preg-
nancy rose in 1967 to the same number as in 1963. This emphasises the need for
continuing scrupulous attention to antenatal care. The general practitioner as
doctor of first contact with the pregnant woman has an important function to
ensure early arrangements for antenatal care whether he elects to provide
maternity medical services or not.

85. The importance of the general practitioner’s share in postnatal care has
received much less attention. The Report of the Royal College of Midwives on
Preparation for Parenthood 1966, showed that many of the women interviewed
had complained that the postnatal services were not as supportive as the ante-
natal services. The general practitioner’s role in relation to the care of the baby
and family planning advice for the mother, in particular, needs to be considered.

86. Guidance on booking policy for domiciliary confinements was given in the
Annual Report of the Chief Medical Officer of the Ministry of Health in 1965
following the findings of the Report on Confidential Enquiries into Maternal
Deaths 1961-63. This aimed at restricting domiciliary confinement to potentially
normal cases.

87. The North West Metropolitan Regional Hospital Board carried out a
detailed survey on four high risk groups: breech presentation, multiple preg-
nancies, elderly primiparae, and grand multiparae, in relation to place of confine-
ment and obstetric management with special reference to perinatal mortality
rates (Law 1967). The report recommended that all cases in the four high risk
groups should be delivered in hospital, with the possible exception of certain
selected grand multiparae.

88. A recent review of domiciliary obstetrics in a group practice (Hudson 1968)
assessed the success of selection of women for home confinement, and concluded
that all primigravidae should be booked for confinement in specialist units.
(Appendix D).

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89. The need for refresher courses in obstetrics for general practitioners has long
been recognised. These enable the practitioner to keep abreast of developments
in the care of mothers and babies. During the 1967/68 academic year there were
1,158 places on courses in Obstetrics and Gynaecology for general practitioners.
Included in these were arrangements for 122 general practitioners to take up
clinical attachments.

90. In May 1962, following a pilot experiment in the Metropolitan area, it was
suggested to Postgraduate Deans that they should approve selected obstetric
units for the provision of a programme of work to be carried out by general
practitioners in the course of unpaid clinical attachments under refresher course
arrangements.

91. We understand that the type of refresher course which seems to be most
appreciated by general practitioners is one which combines a maximum of
practical experience with some formal teaching, and in which the general
practitioner is not treated as “an extra pair of hands”. Where clinical attach-
ments are arranged a regular succession of general practitioners ensures that a
proper scheme of training can be worked out, and we understand that it is
hoped that eventually such schemes will become part of the work of the regional
postgraduate medical, institutes.

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CHAPTER VI

MATERNITY SERVICES PROVIDED BY HOSPITAX

AUTHORITIES

92. The general arrangements for providing maternity services in hospitals under
the leadership of the consultant obstetrician have not changed since the report of
the Cranbrook Committee.

93. The number of consultant obstetricians appointed by Boards of Governors
of Teaching Hospitals and Regional Hospital Boards to be in charge of obstetric
units has increased steadily since the National Health Service began. Comparative
annual figures from 1959 are shown in Table 20 (page 78). The regional distribu-
tion of consultant and general practitioner maternity beds according to Regional
Hospital Boards, together with the number of obstetric consultants (whole time
equivalent) per million population in 1968, is shown in Table 21 (page 78),

94. The volume of work has, however, undoubtedly increased since 1959
because of the higher hospital confinement rate, the increased turnover of
patients made possible by earlier discharge, and changes in clinical management
of patients including an increase in operative deliveries.

95. The increase in the number of cases of deliveries in hospitals, forceps
deliveries and Caesarean sections for 1958-1966, with total estimated numbers
and percentages in England and Wales (H.I.P.E. data) is shown in Table 22 (page
79). Table 23 (page 80) reflects other changes in the pattern of hospital maternity
service provision which have substantially, over the years, increased the work for
which the consultant obstetrician is ultimately responsible. As the leader of the
obstetric team, the consultant’s responsibilities include the organisation of the
emergency flying squads, evidence concerning which was sought from Senior
Adminstrative Medical Officers of Regional Hospital Boards and will be con-
sidered in a later chapter.

96. The consultant also has important liaison duties within the obstetric team,
both inside and outside the hospital, and between the team and other pro-
fessional colleagues. This usually includes serving on the local maternity liaison
committee, local obstetric committee, and other bodies. His liaison with the
consultant paediatrician, whose contribution to the care of the baby in stressed
later in this report, is of growing importance.

97. In connection with clinical work, many consultants arrange in-service
training for colleagues and members of the obstetric team, and in certain
hospitals engage in the teaching of undergraduates and postgraduates, and carry
out research programmes.

98. The First Report of the Joint Working Party on the Organisation of
Medical Work in Hospital devotes a whole chapter to the key role of the

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clinician in administration and management, and it is evident that a more
clearly defined managerial role is foreseen for the consultant in the hospital
service of the future. In the context of that Report obstetrics and gynaecology
would together constitute a Hospital Division. Consultants appointed Chair-
men of such Divisions would find themselves also concerned with services such
as family planning, the importance of which in the practice of modern obstetrics
is touched upon in a later chapter.

99. The provision and siting of general practitioner beds in relation to consult-
ant obstetric units and the relationship and division of responsibility between
consultants and other hospital staff and the general practitioners are matters to
which reference will be made when we consider the evidence which we have
received.

100. In general every young doctor planning to make a career in the hospital
obstetric service aspires to, but relatively few can hope to achieve, consultant
status. The present number (whole-time equivalents) and distribution of hos-
pital medical staff in obstetrics and gynaecology is shown in Table 24 (pages 82 &
S3). In 1968 the number of consultants, 555, compared with 537 in 1967. Of the
555 consultants, 484 were male and 7 1 female. The total number of senior hospital
appointments in the specialty (consultants, senior hospital medical officers and
medical assistants) was 591 in 1968. It is estimated that 719 will be required in
1977. Actuarial calculations suggest an annual number of vacancies in the
•consultant grade of about 30.

101 . At present the average age of qualification is between 24-25 years. In theory
doctors should be ready for consultant posts by the age of 32. Because of the
excess of other posts over consultant posts in the specialty, doctors are spending
far longer than necessary in the training grades. Of the 34 consultants appointed
between 1st October 1967 and 30th September 1968, only one was under the age
of 35, 21 were aged 35-39, and 12 were over 40.

102. The number of senior registrars in the specialty on 30th September 1968
was 85, of whom 78 were born in the British Isles (including Republic of Ireland);
there were 159 registrars born in the British Isles and 248 who had been bom
•elsewhere. Table 25 (page 84) shows the number of years they had spent in the
registrar grade. The registrar grade was originally envisaged as a training grade
for hospital specialists to be held for 2 years. It is therefore apparent that the
hospital service is training about 200 doctors a year, of whom 80 are British, for
senior registrar posts, of which only about 25 fall vacant yearly. Of the 78
British-born senior registrars in post on 30th September 1968, 8 had been in the
grade more than 3 years.

103. A total of 309 doctors took up senior house officers posts in the specialty in
1968. They joined 256 doctors who had already passed a year or more in the
grade.

104. A histogram is attached (Table 26 (page 85)) showing the relationship
between the theoretical output of British doctors from the registrar and senior
registrar grades to the demand for consultant posts: From this it would appear
that there are too few senior registrar posts. However, because of the large
number of highly trained and experienced people occupying academic posts and
working as locums there are more recruits for consultants posts than there are

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vacancies. In 1968 there were on average 22 applicants for every consultant
appointment, and it is clear that a serious imbalance exists which, it would seem,
may only be corrected by changes in the numbers recruited into training grades
or by increasing the number of consultant posts in the specialty.

105. The Cranbrook Report (1959) recommended hospital provision for a
national average of 70 per cent of all confinements, a stay of 10 days after con-
finement in the normal case and the provision of seven antenatal beds per 1,000
total births. This suggested a ratio, linked to a birth rate of 16*6 per 1,000 of
0*58 beds per 1,000 general population.

106. In 1968 there were 23,035 maternity beds in National Health Service
hospitals representing 0-46 beds per 1,000 total population. Of these beds 4,882,
or about 21 per cent, many of them in small units of under 10 beds, were staffed
by general practitioners. In 1955, general practitioner beds constituted only 13
per cent of the total. Most of the additional hospital maternity beds that have
been provided in recent years have been allocated to general practitioner
obstetricians. It was estimated from figures obtained in the Hospital In-Patient
Enquiry that in 1966 21*8 per cent of all deliveries in National Health Service
hospitals took place in general practitioner beds. Departmental statistics show
that a very considerable proportion of these beds are contained in very small
units and we understand that it is the Department’s intention continuously to
review their provision and to replace them, where possible and as the opportunity
offers, with larger combined consultant and general practitioner units. The
average total duration of stay in general practitioner beds was 6*8 days in 1968
compared with 8*0 days in consultant beds. Table 21 (page 78) shows the regional
distribution of consultant and general practitioner beds according to Regional
Hospital Board areas.

107. Although the Cranbrook target figure of 70 per cent hospital confinement
has already been reached and this upward trend is likely to persist, the increase is
not uniform. In 1968 there were local authority areas in which the domiciliary
confinement rate was as high as 40 per cent. In other areas the hospital con-
finement rate is so high that the residual domiciliary midwifery service requires
disproportionate and uneconomical staffing if full cover is to be provided.
Furthermore there are difficulties in precise forecasting of future birth rates
which may be affected by social factors, the availability of family planning advice
and the number of pregnancies terminated under the Abortion Act.

108. McEwan (1967) considered that the time had come for revision of the
Cranbrook-based maternity bed ratio. He analysed recent trends; the number of
births had increased by 30*3 per cent between 1955 and 1964 and the number of
births in N.H.S. hospitals was 41 *8 per cent greater in 1964 than in 1955. To deal
with the rise in case load there were only 1,592 (8*1 per cent) more allocated
maternity beds in 1964 — an increase confined almost entirely to general prac-
titioner beds. The greater turnover had been achieved by shortening the length of
stay, which had declined steadily year by year. It was argued that if the reduction
in the average duration of stay nationally continued at the same rate as between
1955 and 1965 a length of stay of 5*5 days would be reached in general prac-
titioner maternity units in 1971 and in consultant maternity units in 1973. An
average duration of stay of 5*5 days and an average bed occupancy of 80 per cent
applied to the 1965 population and total births would require 16,510 maternity

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beds and a new planning ratio of 0-35 maternity beds per 1,000 population. If an
average duration of stay of 7*6 days were substituted for 5*5 days then the
national norm would be 0*48 beds per 1,000 population. McEwan concluded
that the true requirement must lie between 0*35 and 0*48 maternity beds per
1,000 population and that with a new ratio of this order the rapid replacement of
old functionally poor accommodation should be possible.

109. Marshall (1967) in commenting on McEwan’s article stated that no hos-
pital planner would use a norm based on population alone to calculate the
number of maternity beds required. He would first try to estimate the number of
births likely to take place in the area to be served and decide on the percentage of
births for which he wished to make hospital provision. He considered the con-
cept of average length of stay fallacious in maternity bed planning and advocated
instead the use of a throughput figure. In the Manchester Region for example,
the throughput per lying-in bed has risen from 24-36 patients a year in the past
10 years. McEwan’s suggested throughput of 53 patients per year, is higher than
any at present obtaining. Table 27 (page 86), from the National and Regional
Hospital Service Statistical Profile 1967, shows staffed beds and throughput in
relation to the institutional and the hospital confinement rates.

110. Golding (1967) drew attention to the considerable variation in birth rates
even between areas within a hospital region; eg. Islington had a birth rate of
24*0 per 1,000 in 1965 whilst the corresponding rate was 14*8 per 1,000 in West-
minster. He pointed out that a new town in the early stages of settlement could
have a birth rate considerably above the average. This suggested that because of
the difficulty of accurate prediction maternity units should be built so that some
of the beds might be used for other specialties, and that isolated maternity units
should not be built.

111. The obstetric aspects of the early discharge of maternity patients were
reviewed after a scheme had been in operation for 9 years in Bradford, and 5,000
consecutive case records of patients discharged from hospital within 60 hours of
delivery were analysed (Craig and Muirhead (1967)). It was concluded that
planned early discharge did not result in increased maternal morbidity, nor did
it add to maternal risk. The scheme was considered to be an efficient and eco-
nomical way of providing the safety of hospital delivery for the maximum
number of mothers and babies. It was pointed out, however, that consideration
should be given to the provision of suitable accommodation for mothers and
babies where readmission became necessary. The readmission rate was less than
1*0 per cent.

112. A complementary enquiry (Arthurton and Bamford 1967) into the paedia-
tric aspects of early discharge in Bradford found “There is no evidence that early
discharge offers any advantage for the individual baby as compared with staying
in hospital for 10 days, and in fact there are additional risks partly attributed to
difficulties in neonatal diagnosis”. The authors considered it preferable to avoid
the need for readmission, and said that in their experience this would have been
reduced by 59 per cent if mothers and babies left hospital on the fifth day.

113. The high perinatal mortality rates compared with some other countries and
the * avoidable factors revealed in the Confidential Enquiries into Maternal
Deaths indicate the need for still greater attention to in-patient antenatal care,

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and for a sufficient number of antenatal beds for complicated pregnancies to be
available.

114. It will be clear from what is said above that it has, for some time, been
known that the Cranbrook recommendations for hospital bed provision are no
longer relevant to the changing situation. Because of this, while the planning of
new hospitals and maternity units has had to continue, no reliable national
target figure for bed provision has been available, and to some extent an ad hoc
estimation has had to be employed. The trend towards a shorter average stay in
hospital after delivery is significant and must affect future planning.

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CHAPTER VII

THE CARE OF THE BABY BEFORE AND AFTER

DELIVERY

115. The concern of the obstetric services has been to reduce the hazards of
childbirth, not only for the mother, but also for the child. It is for this reason that
we briefly review infant mortality, and consider the care that should be given to
the baby, although these subjects are not strictly within our terms of reference.

116. At the end of the last century the infant mortality rate in England and
Wales was over 150 per 1,000 live births. The present infant mortality rate is 18-0
per 1,000 live births. The general decline in infant mortality has, however,
brought new problems. Infants suffering from mental and physical handicaps
who would have died twenty years ago are now surviving in increasing numbers,
and a substantial proportion of them have multiple defects.

117. Table 28 (page 86) shows that notwithstanding the overall decline in infant
mortality rates the first week continues to be a critical period during which there
is a particular need for expert care.

118. Perinatal mortality (i.e. the number of stillbirths and the number of infant
deaths in the first week of life per 1,000 total births) in England and Wales has
been recorded since 1928, when the rate was 60*8 ; it rose to its highest value of
63*4 in 1933, before declining with only slight fluctuations to a level of 24*7 in
1968. There are, however, considerable regional variations (Table 8, page 70),
important causes of which may be the social background of the mothers and the
relationship of this to age, height, parity and general health, and the standard of
obstetric care. The commonest causes of first week deaths are birth injury and
asphyxia, immaturity and congenital malformations. About 7 per cent of all
births are premature according to the international definition. Low birth weight
predisposes infants to special hazards such as respiratory and nutritional dis-
orders and impaired mental and physical development.

119. Good nutrition during pregnancy is important. Any deficiency in early
pregnancy, for example of folates, may interfere with the formation and develop-
ment of the foetus, particularly its central nervous system. The need for early
prevention and intensive treatment of anaemia during pregnancy is particularly
important.

120. The need for detailed surveillance throughout the antenatal period, in the
interests of the child, has assumed greater importance. More accurate methods
of monitoring foetal growth and development are being perfected, and these
promise to be of help in determining how long to allow a toxaemic pregnancy to
progress towards term to reduce the degree of prematurity. The development and
widespread adoption of these techniques, together with the artificial induction of
labour, has important implications for the provision of antenatal beds and
delivery suite accommodation, considered in a later chapter.

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121. Another important cause of death has been haemolytic disease of the new-
born, accounting for a mortality rate of 0*35 per 1,000 live births in 1967.
Attempts have been made for many years to prevent or minimise the haemo-
lytic process. The discovery of a practical method of prophylaxis against rhesus
iso-immunization which Clarke and his colleagues first reported in 1958 (Clarke
et al 1958), and his subsequent work in this field (Clarke 1968) is an important
step towards reducing the mortality of this condition; but much is dependent in
the first instance upon the routine estimation of rhesus blood groups during
antenatal care.

122. The dangers to the newborn infant of birth injury and asphyxia are well
known. All those concerned with the management of the newborn infant should
be able to recognise when intervention is necessary and what form this should
take. If resuscitative measures are to be effective, the clinical appraisal of the
infant at birth and a continuing appraisal in those infants in whom respiration is
not normally and rapidly established is essential.

123. Although there are certain predictable factors which suggest that the
delivery should take place in a specialist unit, nevertheless an asphyxiated infant
may well result from a “normal” delivery in a general practitioner unit or in the
home where care is being given by the general practitioner or midwife. Tizard
and Davis (1967) gave detailed advice on resuscitation in the home and con-
sidered that “a doctor should not undertake domiciliary midwifery unless he knew
how to resuscitate a baby in terminal apnoea,”

124. The reduction in postnatal stay in hospital (Table 2, page 67) together with
the fact that the first week is a critical period in infancy have important implica-
tions In planning for neonatal care. Various aspects of the present trend towards
delivery in hospital, followed by early discharge with further care by the domi-
ciliary midwife, and by the health visitor, have already been mentioned in this
report. There has, however, been no controlled study of the effect, both immedi-
ate and late, on the baby of shorter and longer stay in hospital to establish with
certainty whether this practice offers the best way of achieving a satisfactory
service for the child. A few studies have been published assessing the effects of
early discharge on the baby: Heilman et al (1962), Pinker and Fraser (1964),
McEwan (1964), Arthurton and Bamford (1967). The last showed that there was
no statistically significant difference in mortality rate between babies bom in
hospital, but discharged home before the tenth day, and those bom at home
during the period under review. Similarly there was little difference between the
admission rate to hospital within the first ten days after birth of babies born in
hospital and discharged early, and those born at home. Babies discharged before
the age of 24 hours required readmission significantly more often than those sent
home on the second day.

125. The report of the Sub-Committee of the Standing Medical Advisory Com-
mittee on the prevention of prematurity and the care of the premature infant
(1961) recommended the settingup of special care baby units in large maternity
units for the care of premature infants as well as mature infants requiring special
care. The Sub-committee recommended that six special care cots should be
provided for every 1,000 live births in the area. In 1966 some 63,000 infants were
admitted to special care baby units; the median duration of stay was 12*5 days.

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126. Recent advances in knowledge of the physiology and biochemistry of the
newborn have increased the range and complexity of monitoring techniques. In
view of this it has been suggested that neonatal units for general care should be
provided in the maternity departments of district general hospitals, while
facilities for more highly specialised care are concentrated at regional centres. In
some large hospitals it might be possible to have a combination of both types of
unit. More information is needed about the categories of infants and the
numbers requiring intensive care. A review of the present arrangements for
special care of newborn infants has been undertaken by the Department and the
subject is now under consideration by an expert group, under the chairmanship
of Sir Wilfrid Sheldon.

127. The medical examination of the newborn infant is regarded as essential.
Medical and nursing staff concerned with the care of the neonate require training
and experience in routine screening tests for the early detection of defects, in-
cluding attention to the possible presence of hidden defects. Consultant obstet-
ricians, general practitioner obstetricians and midwives, who very often carry
out the first examination of newborn babies have a special opportunity of
recognising the presence of conditions which require urgent specialist attention
and therefore the primaiy responsibility for recognising the need and arranging
for the transfer of such babies to specialist care without delay.

128. Besides its importance to the individual and his family, the detection of
congenital abnormalities has a wider, epidemiological implication. This has been
recognised by the institution of a voluntary system of notification of congenital
malformations in England and Wales. The main purpose of the scheme is the
early detection of any trends resulting from the use of drugs or exposure to any
environmental factor such as an epidemic of virus disease during the mother’s
pregnancy. In order that this may be done effectively, notifications must be
received as early as possible and the information given is limited to malforma-
tions observable at birth. This has now been in operation for several years, and
the data from the notifications is coded and processed by the General Register
Office. The number of notifications of each type is printed monthly and is
available to Medical Officers of Health and any significant increase in an area is
brought to the notice of the Medical Officer of Health in order that he may
investigate it.

129. Apart from defects which are obvious at birth there are others which must
be sought for or which manifest themselves at a later stage of development. It
has now been fairly well established that certain factors in the prenatal, perinatal
and postnatal history carry a greater than average risk that the baby will have or
will develop abnormalities. Nearly all local health authorities are now keeping
registers of children in the group considered specially at risk of handicapping
conditions. Most Medical Officers of Health and paediatricians feel that the
concept of the child at risk has focussed attention on the potentially handicapped
child and should ensure careful identification and surveillance. It is evident,
however, that such registers would have greater value if there was more selection
on an individual basis for admission to them.

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CHAPTER VIII

EVIDENCE

130. In describing the present situation in the various separate branches of the
service and in setting out the problems with which the Sub-Committee are con-
cerned, earlier chapters have already given some indication of the changing
attitudes both of professional personnel and of the general public. The Sub-
committee have, since they began their work, received in evidence Reports
published by several of the bodies concerned professionally with the maternity
services. These Reports and other evidence in the form of statistical papers pre-
pared specially for the Sub-Committee will be discussed later in this chapter.
First, however, it is proposed to consider the evidence sought directly by the
Sub-Committee.

Medical Officers of Health

131. The form of questionnaire addressed to Medical Officers of Health of all
local health authorities in England and Wales is attached as Appendix E. Of 174
questionnaires despatched in October 1967, 167 were returned in time for inclu-
sion in the survey. Figures quoted in the following paragraphs relate, unless
otherwise indicated, to these 167 authorities who employed, in all, the whole-
time equivalent of 4,843 midwives (3,437 whole-time, 3,427 part-time), 94*6 per
cent of the total for England and Wales (5,118).

132. Relevant comparative statistics over the past 10 years have already been
discussed in Chapter IV, and it is not therefore necessary to restate here the
trends which they revealed, and which were confirmed by the replies to the
questionnaire. Other statistical material from the replies concerning vacancies
and wastage of midwives, deliveries attended by domiciliary midwives, cases
discharged from hospital visited by domiciliary midwives, training in domiciliary
midwifery and changes in deployment of domiciliary midwives is shown in
Tables 29 to 33 (pages 87-90) which are largely self-explanatory, and the follow-
ing paragraphs are concerned only with those features of the statistical data
which appear relevant to the main problems.

133. Table 30A (page 88) shows that 99 per cent of the confinements attended by
domiciliary midwives took place in patient’s own homes, and reflects the very
small extent to which, at the time of the survey, as Tables 30A and 30B show, the
skills of domiciliary midwives were being utilised in hospitals. In the country as
a whole domiciliary midwives on average attended 27 confinements annually,
those employed by 49 authorities averaged less than 20, and 1,321 midwives
actually attended 5 or less. Many of these midwives were employed for the rest of
their time in antenatal and postnatal care, while others worked also as home
nurses or on other non-midwifery duties for which they are qualified. The latter,
however, together with other part-time employed midwives totalling some 50
per cent of all domiciliary midwives, almost certainly attended, on average,

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fewer confinements annually that their full-time colleagues. While attendance at
confinements is only one aspect of midwifery care, it is an important one, and
the need to maintain all midwifery skills by practice is supported by the
opinions recorded in Table 30E.

134. As was pointed out in Chapter IV, the proportion of midwives’ time spent
on the postnatal care of women and babies discharged early from hospital has
increased considerably over the past 10 years; Tables 31 A and 3 ID (page 89)
relate both to these women and to others discharged from hospital, i.e. those
following a stay of more than 10 days, most of whom do not require the services
of a domiciliary midwife. It is evident from a comparison of the numbers of cases
summarised in Table 31 A (page 89) with figures available from hospital statis-
tics that domiciliary midwives attended only about half of all women discharged
after hospital confinement. Of the discharges covered by the survey for which the
duration of stay was known, 97 per cent fell within the ten day period and as
many as 15 per cent occurred within 48 hours of delivery. The peak seems to
occur in the range 5-7 days, and the majority of discharges, 72 per cent, took
place after stays of 7 days or less.

135. Tables 31A to 31D (page 89) bring out quite marked differences in practice
in the areas of different kinds of authority, particularly (Table 3 1C) in the extent
to which domiciliary midwives visited women discharged from hospital. The
average percentage of hospital-confined women visited varied from 75 per cent
in Wales to 17 per cent in London Boroughs. On the other hand Table 31 A
shows that the percentage of very early discharges, within 48 hours or less after
delivery, in the London Boroughs. (33 per cent) was markedly higher than the
average (15 per cent) for England and Wales or that for Wales alone (11 per
cent). These figures exemplify local variations both in hospital practice and in
local authority policy with regard to domiciliary midwifery provision.

136. It is of some interest that as many as 1,198 domiciliary midwives were
either solely engaged, or willing to be solely engaged, in the postnatal care of
“early discharge” cases. Table 3 IE (page 89) suggests that willingness to under-
take this kind of work exclusively was evinced to much the same degree (by
approximately 15 per cent of all midwives) by midwives in all types of authority
except those in Wales, where the proportion was as high as 40 per cent. It seems
likely that most of the midwives concerned were working part-time in their pro-
fessions, since this kind of work is particularly suited to married women and
others who are unwilling to be at risk of call at any time of the day or night. On
the basis of this assumption it would seem that something approaching one third
of part-time domiciliary midwives may be willingly available for a form of duty
which the full-time midwife might find somewhat unsatisfying.

137. Local health authorities provide the facilities for community experience
which pupil midwives must receive during their training. Tables 32A and 32B
(page 90) show that most authorities participate in training and that substantial
provision is made to receive pupils from other authorities’ areas.

138. Tables 33A to 33D (page 90) record the extent and nature of redeploy-
ment of domiciliary midwives which local health authorities have found
necessary over the past few years. The reasons for redeployment are various, but
of the 107 authorities who reported such changes 40 related them solely to the

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decreasing domiciliary confinement rate; a further 49 had changed the range of
midwifery duties for this and other reasons; and only 18 had made changes for
reasons wholly unrelated to the consequences, in terms of “early discharges”,
of a rising hospital confinement rate.

139. The extent to which the content of the domiciliary midwife’s work has
changed as a result of the changing pattern of obstetric practice has already been
noted. Redeployment within the skills of the profession is, however, only one, if
the major, aspect of the changes which have given rise to this Sub-Committee’s
existence. What is perhaps equally relevant in the present context is the extent to
which local health authorities reported more radical changes in the ways in
which their midwives were employed.

140. Of the authorities mentioning reasons, other than a higher institutional
confinement, for redeployment, 34 referred to extension of home nursing duties
for staff employed as home nurse/midwives. Other changes mentioned included
assistance in cervical cytology clinics and family planning clinics. These trends,
combined with a reported increase in work in antenatal and mothercraft
clinics, suggest that the number of individual midwives employed in the local
authority service is not related solely to the case load of domiciliary confine-
ments.

141. Medical Officers of Health were invited to express their views on the form
of administration of midwifery services. Of those who offered opinions on future
organisation 69 were in favour of some form of unification of the hospital and
domiciliary services, 43 would welcome closer co-operation between the services
as at present administered, 26 saw no need for change and 7, seeing difficulty in
considering these services in isolation from the Green' Paper proposals, sug-
gested interim measures. These views, in cross section, were not clearly related
either to geographical disposition or to types of authority, and it must be con-
cluded that a considerable majority of Medical Officers of Health recognise a
need to meet the changing pattern of demand in the country as a whole.

142. Certain points were recurrent in the views expressed, among them:

(a) the importance of maintaining midwifery skills;

(b) the need for redeployment of midwives to enable them to work in hos-
pitals and general practitioner units in order to

(i) retain their skills;

(ii) relieve hospital staffing problems;

(iii) achieve job satisfaction;

(iv) improve training facilities;

(v) achieve continuity of patient care;

(c) the desirability of attachment of midwives to general practice;

(d) the need to consider the future role of the supervisor of midwives;

(e) the fear that a hospital orientated service might lose sight of community

needs; and

(/) the inevitability that some form of domiciliary service would have to be

retained.

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Chairmen of Local Medical Committees

143. While aware that the Royal College of General Practitioners had set up a
working party on Obstetrics in General Practice (the Report of which is con-
sidered later in this chapter), the Sub-Committee thought it desirable that
evidence should be sought directly from general practitioners on certain specific
matters. Accordingly, letters were addressed to the Chairmen of Local Medical
Committees asking for their ideas on the part which general practitioners might
play in possible co-operative pilot schemes in their areas, and their views on a
number of particular aspects of the maternity services, both present and future.
The Sub-Committee were assisted in this enquiry by the British Medical Associa-
tion, who undertook the collation and analysis of replies and prepared a report,
which is attached as Appendix F (page 107). The section headings of this Report
reflect the specific aspects on which views were sought.

144. The response to this enquiry (58 per cent) was less than had been hoped for,
and the reasons for the failure of 42 per cent of Chairmen to reply are not known.
The Report at Appendix F makes the point that all the views expressed are of
doctors either directly involved in, or particularly interested in, the maternity
service, and for this reason they are both relevant and valuable, but it seems
likely that at least some doctors in the majority of the non-respondent areas
must inevitably be involved in the provision of maternity services.

145. It seems probable from paragraphs 4 to 9 of Appendix F that notwith-
standing the majority of responding Chairmen recording views in favour, or
acknowledging a need for continuance, of domiciliary midwifery, no extremity of
view is prevalent. General practitioners are clearly aware that the indications,
both medical and social, for home confinement need to be much more stringently
assessed than those for a hospital confinement, in which risks are minimised. The
wishes of mothers, and the psychological advantages for some women of having
their babies in familiar surroundings are considered but it is evident that general
practitioners would not allow such considerations to override physical risks.
Even among those doctors who favour a continuance of domiciliary midwifery
there is a recognition that midwives undertaking this work should also work in
hospitals to maintain their professional skills.

146. Paragraphs 10 to 14 of Appendix F present substantial unity of view about
the need for general practitioners to play an important part in the provision of
hospital maternity services. Some of the difficulties expressed in paragraph 10 of
the Appendix have already affected the progress of experimental schemes under
which general practitioners have been given honorary contracts to undertake
maternity work in hospitals. In particular the principle of continuity of treat-
ment is difficult to achieve unless general practitioners are able to find time to
specialise in obstetrics at the expense of other calls upon their services, a situation
seldom realised outside group practices organised to permit such freedom to
certain of its members. Paragraph 14 of the Appendix adds the important
qualification that the general practitioner obstetrician must meet certain
standards of efficiency if he is to be accepted within the hospital service. So far as
the use of hospital beds by general practitioners is concerned, the desire of a
small majority of respondents for completely separate general practitioner units
is tempered by an awareness of the need for ready access to a consultant unit
when complications manifest themselves.

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147. The views expressed on attachment of domiciliary midwives to general
practices, in paragraphs 15-20 of the Appendix, have given its compilers occasion
to draw attention to administrative problems which would arise if the midwives
concerned were, as many doctors thought they might be, hospital based. The
attachment of local authority nursing staffs to general practices currently
depends for its success upon the concept of a team all of whose members are,
throughout their working hours, concerned only with those patients on the
practice list. 45 per cent of those responding not only favoured the extended use
of domiciliary midwives in hospitals but considered that in a reorganised service
all midwives should be hospital based, and that the domiciliary service should
be provided on a rota system under which midwives would undertake, in turn,
both hospital and domiciliary work. It was also suggested that district work not
calling for midwifery skills should be carried out by other workers and the
present law, unlike Section 23 of the National Health Service Act 1946 (now
repealed and superseded by Section 10 of the Health Services and Public Health
Act, 1968) leaves no doubt that local health authorities are empowered to pro-
vide the necessary services.

148. Views expressed in paragraphs 21-24 of the Appendix on the means by
which a close relationship between the general practitioner obstetrician and the
consultant obstetricians should be established, and indeed on the precise nature
of the relationships, varied and personalities were thought important. General
practitioner obstetricians are evidently highly conscious of limits of responsi-
bility, but in paragraph 24 it is also apparent that they are less enthusiastic about
definitions which would set those limits. The suggestion in paragraph 23 of the
Appendix that a consultant obstetrician might take over responsibility for
difficult cases would imply some revision of the present definitions, under the
Maternity Medical Services, of partial and complete antenatal care. There is,
however, general agreement that the consultant should see every patient at
critical times during pregnancy. With regard to the setting up of obstetric liaison
committees on the lines suggested in paragraph 22 of the Appendix, maternity
liaison committees already exist, and it is to be assumed that the suggested
obstetric committees would in effect act as sub-committees of the main maternity
liaison committees, concerning themselves particularly with the common use of
hospital maternity facilities by both consultants and general practitioners.

149. Paragraphs 25 to 30 of the Appendix indicate that not all general prac-
titioners see their future role within integrated units, and that there remains
considerable support for the existence of separate general practitioner obstetric
units, although here again the importance of proper equipment and ready access
to consultant cover is unanimously acknowledged. The provision of arrangements
to meet local conditions is regarded as important, and the alternatives of either
an on-call rota system or notifying the patient’s doctor when she is in labour are
suggested for the provision of effective medical cover. In paragraph 29 of the
Appendix, however, it is envisaged that if a general practitioner could not attend,
the hospital would take full responsibility. Paragraph 26 lays stress on the need
to see a general practitioner obstetric unit as an integral part of general practice,
although it would be staffed (otherwise than medically) by hospital-employed
nurses and midwives.

150. An alternative status for the general practitioner obstetrician is discussed
in paragraphs 31 to 34 of the Appendix; although there was universal support

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for the appointment of general practitioners as clinical assistants, respondents
appear generally to have envisaged practical difficulties in introducing such
appointments on any scale. The educational value of hospital work for general
practitioners is acknowledged, although here again a primary objective is seen
as the future staffing of general practitioner maternity units.

151. Of the very high proportion of respondents commenting upon the obstetric
list (paragraphs 35 to 39 of the Appendix) only about a quarter saw it as an out-
dated formality, and it is not entirely clear whether they also acknowledged that
incorporation of maternity work within general medical services might mean the
end of special payments to doctors for providing such services. Many recognised
a need to limit the practice of obstetrics by some means so as to ensure that
maternity services are provided only by those general practitioners with special
competence, and suggested that retention on the obstetric list should be subject
to periodical review to ensure that skills are satisfactorily retained. In paragraph
39 of the Appendix the hope is expressed that obstetric specialisation will
ultimately be concentrated within group practices.

152. In paragraphs 40 and 41 of the Appendix, dealing with training and main-
tenance of skills, respondents had little to add to the views expressed in the
Report on Obstetrics in General Practice published by the Royal College of
General Practitioners, and it seems appropriate, therefore, to consider this topic
later when reviewing the College’s Report as a whole.

153. A substantial minority of respondents, presumably themselves working in
rural areas, expressed concern about the provision of adequate services in those
areas; possible ways of doing so are put forward in paragraphs 42 and 44 of the
Appendix.

154. Paragraphs 45 and 46 of the Appendix offer no single new view on the
place of the general practitioner obstetrician in a unified maternity service, but
repeat in brief the opinions already dealt with above. Some doctors, like some
of their Medical Officer of Health counterparts, thought that the future of the
maternity services could not be considered in isolation from other possible
changes in the health services as a whole.

Senior Administrative Medical Officers

155. The form of questionnaire addressed to Senior Administrative Medical
Officers of Regional Hospital Boards in England and Wales is attached as
Appendix G (page 116). In a covering letter Senior Administrative Medical
Officers were asked to consult with the Secretaries of Boards of Governors in
their Regions before formulating their replies. The resulting statistical material
is contained in Tables 34 to 44 (pages 91-94). Reference is made to particular
Tables in the following paragraphs.

156. Table 34 (page 91) shows that in all regions general practitioner beds are
provided predominantly in completely separate general practitioner units. For
the country as a whole 80 per cent of such beds are so sited, and of the others,
only three quarters are situated in close proximity to consultant wards.

157. The replies to Question 2 in Appendix G did not lend themselves to tabula-
tion, mainly because the totality of “areas” mentioned could not be statistically
related, by size, to the country as a whole. In three regions it was indicated that
the requests of priority groups were fully met, but in the other regions there were

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43 areas in which additional beds and related services would be needed to meet
such requests. Other requests (i.e. not on priority grounds) could not be met in
84 areas, spread over most of the regions (two did not find it possible to give
answers to this question). Deficiencies in facilities were spread fairly evenly over
those named at the heads of columns 4-7 in Question 2.

158. All regions but one reported difficulties in staffing existing maternity units.
Various reasons were given, among them:

(a) Poor transport facilities and lack of social amenities, particularly in iso-

lated units.

(b) Lack of suitable residential accommodation.

(c) Old buildings, overcrowded wards and excessive work loads arising from

the increase in hospital confinements associated with early discharge.

(i d ) The unpopularity of night duty.

(e) The reduction in salary suffered by S.R.N.S undertaking midwifery
training.

(/) The higher starting pay available to a newly qualified midwife entering
the domiciliary service.

( g ) Higher salaries paid by nursing agencies.

(h) Competition with local industry.

(0 Limited experience and poor promotion prospects in small units in rural
areas,

O') A preference by staff for work in large teaching hospitals or districts
attracting London Weighting.

159. Table 35 (page 91) reflects a wide divergence of views in certain regions.
Only 256 out of 651 maternity hospitals have specific catchment areas, although it
is thought that such areas could be defined for a further 141 ; in the remaining
254 cases the possibility is not accepted. In five regions complete definition could
be achieved while in three others no catchment areas could be specified at all;
the rural or urban nature of the regions concerned appears to bear little relation-
ship to the views expressed, and it seems possible that the concept of a catchment
area may have been grasped differently by different respondents.

160. The answers received to Question 5 (Appendix G) related to 196 emergency
obstetric services (flying squads) of which one, recently formed, had not become
operative at the time of reply. While there was general agreement that ideally a
squad should consist of a consultant or registrar (usually the latter), an
anaesthetist, a midwife and a pupil midwife or medical student, the actual com-
position of teams varied, as the summary of personnel in Table 36 (page 92)
shows. For 134 of these visits squads used ambulances, private cars or taxis
being employed for 55 others; information was not given in the remaining 6
cases. Tables 37 and 38 (page 92) give some indication of the average and maxi-
mum durations and distances of outward journeys, the majority of which do not
exceed 10 miles and take less than 30 minutes. Nevertheless, a number of squads
are called upon to undertake occasional journeys in excess of 20 miles or, more
significantly, lasting over 45 minutes. Table 39 (page 93) which is based upon
such information as could be provided and reflects figures, some of them incom-
plete, returned in respect of 175 squads, indicates the wide variety of situations

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encountered. Nearly one in seven of the calls were received from general
practitioner units many of which, as is mentioned in paragraph 156 above, are
situated at some distance from consultant departments.

161. That the provision of hospital-based domiciliary midwifery services is at
present very limited in extent is evidenced by the replies to Question 6 (Appendix
G). Only 12 hospitals* provided such a service, and they employed the whole-
time equivalent of 90 midwives for this purpose, a diminutive proportion of
domiciliary staff as a whole.

162. Table 40 (page 93) records the replies received to Question 7 (Appendix G)
concerning the employment of domiciliary midwives in hospitals; one region
was unable to provide answers to items (c), (d) and (e). (Comparison of these
figures with similar ones returned by Medical Officers of Health discloses minor
discrepancies which, it is thought, have arisen because the latter antedated the
former by about a year). The extent of participation by domiciliary midwives in
hospital work is, as was stated in paragraph 133 above, very small; and the
degree to which they actually relieve pressure on hospital midwives is, as the
answers to item (d) suggest, even smaller. Only 31 domiciliary midwives (whole
time equivalent) are recorded as necessarily helping to staff hospitals.

163. The extent to which midwives were, at the time of the questionnaire, em-
ployed on particular aspects of the total service to the exclusion of others is
indicated in Table 41 (page 93). These figures, to be seen in perspective, need to
be related to a total hospital midwifery establishment of approximately 11,000
(whole time equivalent). Something of the order of one quarter of all hospital
midwives specialised in various ways, and more than half of these did not under-
take deliveries. Question 9 (Appendix G) followed up the point of specialisation,
and the replies suggest that in nearly all regions there is, at least in some hos-
pitals, a continuing trend in this direction. Most aspects of midwifery work were
mentioned as specialties in this context.

164, While specialisation as such could be the result of conscious planning to
achieve rational deployment of personnel within large units, changing patterns
in the provision of maternity services have themselves brought about changes in
work which hospital midwives undertake. Replies to Question 10 (Appendix G)
suggest that in all regions the increase in the number of hospital confinements
has necessitated such changes, but other factors, not all related to this increase,
have also had their effect. Factors mentioned by five or more regions were:

Planned early discharges
Early ambulation
Changes in obstetric practice
More instruction in mothercraft
Central sterile supplies depts.
New equipment

12 regions

8

8

6

5

5

55

5 ?

165. Vacancies for hospital midwives at 31st March 1968 totalled 1,533 (whole
time equivalent), about 14 per cent of total establishment. Table 42 (page 94)
shows the numbers of hospitals with vacancies of varying degrees of persistence.
Vacancies were spread over all regions, but the Manchester hospital region, with

*At the time of the Survey; there have been more recent developments in this direction.

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225 vacancies and 44 hospitals where vacancies had persisted for more than 12
months, appeared to suffer exceptional difficulties. The extent of vacancies in a
particular region did not always appear wholly consistent with replies to
Question 3 (staffing difficulties).

166. Table 43 (page 94) summarises the kinds of reason given by hospital mid-
wives for leaving their employment during 1967; the total number leaving
suggests an annual turnover of the order of 23 per cent. The difficulties of retro-
spection and uncertainty as to the genuineness of reasons given by staff justify
caution in acceptance of these figures, but it is of interest that only a very small
minority made reference to insufficiency of congenial work. It has also to be
borne in mind that some of those leaving for reasons other than retirement may
well have taken up employment as midwives elsewhere, in either the hospital or
the domiciliary service.

167. The replies to Questions 14 and 15 (Appendix G) about midwifery training
schools are summarised in Table 44 (page 94). The table shows that in general
available places are taken up, and indeed in several regions acceptances for
Part I courses exceed the places said to be available. Both places provided and
acceptances for Part II courses are substantially less than those for Part I
courses, and it is evident that these courses are not, in most regions, used to the
full. Detailed consideration of the implications of these figures, from the point
of view of maximal utilisation of resources, may well be academic in view of the
Central Midwives Board’s current concern with revision of the pattern of
training.

168. Two further questions (16 and 17, Appendix G) sought to elicit both the
attitudes of hospital authorities to midwifery training (their need for, and
willingness to establish, new schools), and the primary reasons for their wish to
expand training facilities. Apart from the objective of establishing the new com-
prehensive courses proposed by the Central Mid wives Board, the most common
motive to emerge was a desire to improve recruitment and achieve staff stability.

169. Statutory supervision of the practice of midwifery under Section 31 of the
Midwives Act 1951 has legal effect within the hospital service although the
statutory supervising authorities are local health authorities, who employ
medical or non-medical supervisors to carry out day-to-day supervision. In
Question 18 (Appendix G) senior administrative medical Officers were invited
to comment upon the effect of such supervision on administration. Responses
varied, but greater stress was laid upon the incidental benefits of contact with a
local health authority midwifery administrator (closer co-operation, co-ordina-
tion of hospital and local authority services in early discharge cases, etc.) than
upon the purely technical advantages in a statutory context. Of the latter,
mention was made of the supervisor’s part in ensuring notification of intention
to practise and attendance at refresher courses.

170. The replies to Question 10 (see paragraph 164 above) suggest that the
growing practice of early discharge (which, in this context means discharge
within 48 hours of confinement) has had a significant effect upon the pattern of
work of hospital midwives. Question 19 (Appendix G) was concerned with the
administrative difficulties which might attend this practice, and the reactions of
hospital midwives to it. A majority of respondents mentioned administrative
complications but several of these were relatively minor and not necessarily

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’uniformly experienced throughout individual regions. The most commonly
experienced difficulties were (a) extra clerical and administrative work, and (b)
difficulties in contacting ambulances and domiciliary midwives, particularly at
weekends and bank holidays. Two respondents commented upon the complica-
tion of having to deal with several local health authorities, each with different
procedures. One region referred to an increased work load in wards and delivery
suites. The reported reactions of hospital midwives were mixed; four regions and
one Board of Governors mentioning mainly favourable attitudes and only two
regions indicating positive antagonism. The remaining respondents conveyed an
impression of acceptance of the practice as a necessity, with some reservations.
Adverse comments referred to “conveyor belt” methods with increasing tempo
and pressure of work, a reduction in job satisfaction, diminution of the
midwife/patient relationship and difficulties in establishing breast feeding. On
balance however, despite the criticisms of early discharge, it would seem that a
majority of hospital midwives accept both its inevitability and the fact that it
meets the wishes of many mothers.

171. Replies to Question 20 (Appendix G) about maternity liaison committees,
of which there were 204, revealed considerable variations, both nationally and
within regions, in the frequency with which they meet, intervals varying from
one month to one year. A majority of respondents thought that the committees
were effective, but four thought their effectiveness limited or difficult to assess,
while one regarded existing administrative liaison between the three branches of
the service as so well organised as to render special liaison committees unnecess-
ary. One comment, that the committees lack executive authority, may have
hinted at a means by which the existing machinery might be developed as an
integral feature of a service moving towards unification, although the conferment
of executive functions would require legislative action.

172. Finally, Senior Administrative Medical Officers were invited (Question 21,
Appendix G) to offer their views on the future pattern of services and admini-
stration, and asked particularly to estimate consequential midwifery require-
ments and to comment upon appropriate arrangements for the training of
mid wives. In broad principle the replies revealed a high degree of unanimity, but
inevitably the open nature of the invitation brought responses ranging fairly
widely in detail and emphasis. The following paragraphs are headed to indicate
the main topics upon which comment was offered.

Future pattern of services and administration

173. Eleven respondents were clearly in favour of a unified service under one
authority, and of these eight specified that unification should be based on the
hospital. There was one mention of unification under an Area Health Board;
another, favouring unification under the district general hospital at local level,
went on to comment that administration of maternity services must be con-
sidered with that of medical services as a whole. The remainder, by their general
comments, implied that they were in favour of much closer integration between
hospital and district midwifery.

Hospital confinement rate

174. It was unanimously agreed that the upward trend in hospital confinement
would continue. The following extract epitomizes the general view: “There
seems to be a gradually increasing appreciation in the profession and amongst
the general public that confinement in hospital is the safest arrangement,

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irrespective of considerations of finance or convenience. This trend is likely to
continue until almost all confinements take place in hospital”. Where a forecast
of the hospital confinement rate likely to be achieved was given, it was of the
order of 90-100 per cent.

The future of domiciliary midwifery

175. Arrangements for domiciliary confinements were, in the light of the fore-
casts mentioned in paragraph 174 above, disregarded completely by about half
of the respondents. Four suggested that a hospital based team would undertake
the declining number of cases. Future domiciliary midwifery was seen as being
concerned almost entirely with early discharged postnatal cases. It was thought
that organisation of their care would depend on local circumstances. It was
suggested that in built-up areas hospital-based midwives on a roster might
continue the postnatal care of patients in their own homes. Alternatively, certain
midwives might specialise in ante and postnatal care, and these might be resident
either in hospital or in the community (e.g. married midwives working part-
time).

The role of the general practitioner

176. Nearly all respondents discussed the specific role of the general practitioner
in the maternity service of the future. The majority foresaw his greater participa-
tion in the hospital maternity service through the allocation of more beds for
general practitioners. Mention was made of the advantages of flexibility in the
allocation of maternity beds, and the sharing of labour suites by consultants and
general practitioners. While most replies envisaged an obstetric team, consisting
of consultants and their staffs, general practitioner obstetricians, and midwives
based on a large specialised obstetric unit, several suggested that planned decen-
tralisation to peripheral units would be justified in rural areas. Opinion was
divided as to whether responsibility for potentially normal cases should rest with
general practitioners or consultants, but the point was made that in any scheme
respective clinical responsibilities must be defined. References to the obstetric
list included predictions that a continuing reduction in the number of domiciliary
confinements would lead to a reduction in the number of general practitioners
included therein, and that the advent of group practices would concentrate
maternity work among doctors specially interested in the subject. Revision of
the system of remuneration for general practitioner obstetricians was advocated.

Deployment of midwives

177. The effective deployment of trained midwives was frequently mentioned as
being important for the future of the service. It was thought necessary to look at
the midwifery service as a whole, with patient care of a uniformly high standard
as the objective. The discrepancies between work loads in the hospital and
domiciliary fields in some areas was noted, and a warning was sounded that the
concentration of all deliveries in hospital with extension of early discharge
schemes might overwhelm hospital midwifery staff. A number of respondents
called for the use of ancillary staff to relieve the trained midwife of all non-
essential duties.

Training of midwives

178. About half the comments received were in favour of implementing the
Central Midwives Board’s proposals for a 1-year combined hospital based train-

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mg course. Many considered that the future content of the domiciliary part of
the training should be modified to embrace wider aspects of community care.

Hospital midwifery staffing needs

179. There was least agreement on the possibility of estimating future staffing
needs, and where estimates were made they differed widely. Several respondents
considered that uncertainty about future policy and variable factors such as birth
rate and length of stay made estimations impossible. One thought that the
present rate of recruitment should be adequate to maintain present standards of
service if midwives could be released from non-essential duties, thus increasing
the skilled content of their work. The majority, however, considered that an
increased number of hospital deliveries would necessitate an increase in staffing.
The point was also made that the amount of antenatal and postnatal work under-
taken by domiciliary midwives at present is difficult to evaluate in terms of the
additional hospital employed midwives who would be required to provide a
similar service. Several respondents based their staffing calculations on the
factor, used for establishment purposes, of 2*5 beds/midwife. One, however,
considered this too crude a method by which to arrive at an accurate picture
either of the needs of the patient or of the work potential of the midwife, and
contended that a Nursing Dependency Study was needed to establish a proper
basis for assessing staffing requirements.

Central Midwives Board

180. Representatives of the Board were invited by the Sub-Committee to attend
to offer evidence on certain points, and the Board subsequently submitted a
Memorandum of Evidence which is attached, preceded by a list of the questions
to which the Board addressed themselves, as Appendix H (page 121).

181. While the Board agreed that there should be integration of the present
hospital and domiciliary midwifery services they drew particular attention to
problems which would arise in areas where substantial use is made of district
nurse/midwives undertaking dual functions. They took the view that there will
always be a need for domiciliary midwifery and that certain midwives should be
predominantly concerned with co-operation with general practitioner obstet-
ricians.

182. With regard to the future of midwifery training the Board saw advantages,
rather than difficulties, stemming from closer integration of general practitioner
and consultant maternity units.

183. With regard to the maintenance of midwifery skills, if midwives were
allowed to conduct confinements solely in a diminishing domiciliary field the
Board would rely upon suitable refresher courses.

184. The Board considered that a revision of the statutory provisions for the
local supervision of midwives should be undertaken, and that a distinction
should be made between statutory supervision and the organisation or super-
intending of the service.

185. The Memorandum offered no support whatsoever for the idea of training
midwives to undertake only part of total maternal care, as distinct from special-
isation after complete training.

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186. The Board offered, at item 7 of their Memorandum, specific suggestions for
interim measures designed to achieve closer co-operation between hospitals and
local authorities. Some of these suggested interim measures imply executive
functions which might require legislative action.

Statistical Papers

187. The prediction of bed needs, especially those in delivery suites, is extremely
difficult even if the hospital confinement rate to be aimed at has been decided.
Some attempt can, however, be made to assess bed requirements having regard
to those variable factors which can be numerically defined, and the results
obtained can form a basis for planning, both short-term and long-term, in any
particular region.

188. At our request the Department’s Statistics and Research Division have
produced papers on “Factors affecting the needs for maternity beds” and
“Factors affecting the provision of delivery beds” which are attached as
Appendices I and J (pages 123 and 132). Before turning to the implications of
Table 5 in Appendix I, it may be appropriate to consider to what extent the
several variable factors named in paragraph 1 of that Appendix are amenable to
conscious determination.

189. The paper suggests that a trend towards shorter hospital stay must, in view
of the consequently increased turnover, make it difficult to increase the percent-
age occupancy because the intervals between occupation will not be reduced in
proportion. If the average length of stay continues to fall, percentage occupancy
is thus a factor of secondary significance in determining bed needs.

190. A substantial reduction in the percentage of beds used for antenatal care
cannot be anticipated. The implications for the future are to some extent con-
jectural and it would seem unwise to plan on the basis of a lower percentage than
at present obtains.

191 . The factor most closely related, inversely, to the attainable percentage of all
births in hospital is the postnatal length of stay.

192. Table 3 in Appendix I (page 125) shows that while the percentage of cases
staying up to two days after delivery is increasing steadily, the fall in the average
length of stay owes more to an equally steady downward shift in the 9-10, 7-8,
and 5-6 day groups. With as many as 50 per cent of cases in the first-half of 1968
in the 9-10 day and 7-8 day groups it is evident that a reduction of only one
day’s stay in these groups would bring the average length of stay down to some-
thing like 6 days. The trend is already apparent and a further reduction to an
average length of stay of 6 days or less is likely.

193. On the basis of the broad assumptions that occupancy will remain at about
74 per cent and the percentage of beds used for antenatal care will not fall below
27*5 per cent (the figure shown in Table 1 of the Appendix), and that average
length of postnatal stay can be reduced to 6 days or less, Table 5 (page 126) shows
that with no substantial increase in the total number of beds available (approxi-
mately 23,300), if the beds were strategically distributed, a hospital confinement
rate of 90 per cent is almost currently within reach; and that a reduction in the
average length of stay to 5 days would make a rate of 100 per cent possible by 197 L

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194. Distribution of beds is not, however, by any means even. Regional varia-
tions in demand and present provision upset calculations based upon averages,
and in consequence the prognosis is not uniformly as optimistic as Table 5
suggests. Some 16 per cent of beds are situated in isolated general practitioner
units.

195. While no hypothetical example can take account of all the factors en-
countered in practice, it is of interest to consider the implications of Table 5 for
the planning of a unit to serve a population of 200,000 given a bed occupancy of
85 per cent, an average postnatal stay of 5 days and provision of 25 per cent of
beds for antenatal care. If no other factors intervened 70 beds in such a unit
could accommodate 16 births in hospital per 1000 population. With poor home
conditions necessitating an average postnatal stay of 7 days and a 30 per cent
provision of antenatal beds, 130 beds could accommodate 20 hospital births per
1000 population. These examples are deliberately chosen as less than probable
situations. They demonstrate, however, that a statistical approach can yield
significant results. In the real situation it might be expected, that with a birth
rate of 17 per 1000 population, with 25 per cent beds used for antenatal care, a
six day average postnatal stay, and 75 per cent occupancy of lying-in beds, some-
thing of the order of 0-5 beds per 1000 population, would allow 100 per cent
hospital confinement ; but this kind of calculation cannot be used indiscriminately
for regional planning.

196. The Tables in Appendix I do not take account of beds in delivery suites,
adequate provision of which may be of crucial importance. Statistical treatment
of this problem is bedevilled by several factors and the paper at Appendix J
(page 132) takes account specifically only of the average rate of arrival of
patients, the average time spent in the suite, and the possible effects upon
delivery bed needs of induced labour. Some allowance is, however, made for the
effects of false labour, night deliveries etc. by the addition of fairly substantial
tolerances. Operating theatre facilities for caesarian section, post-partum
sterilization and other obstetric procedures are not included in the calculations.
These needs have not been considered in detail by the sub-committee, being
seen as outside their terms of reference.

197. The paper calls for little detailed comment, demonstrating as it does, in the
same way as the paper at Appendix I, the value of statistical treatment of
problems of this kind. The examples given are based upon satisfaction of
maximum demand, and examination of the tables will show that it is in fact likely
that for a very high proportion of the time provision of fewer beds would suffice.
It can be estimated that in a large maternity unit accommodating 4,400 births
annually, and where the average total stay in the delivery area is as long as 18
hours, the delivery suite requires 26 beds of the combined type to cope with the
peak demand. However, if non-induced patients are transferred after the first
stage to another bed, the total provision needed is slightly higher, viz. 30 beds
composed of 15 first stage and 7 second stage, with 8 of the combined type for
induced cases.

198. The paragraphs above related to evidence sought directly by the Sub-
committee. In the following sections brief reference will be made to the several
reports, policy statements and other documents also received in evidence.

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Report of Council on Hospital Obstetrics and the General Practitioner (Royal
College of Obstetricians and Gynaecologists)

199. In broad terms the Council’s findings are that the time is ripe for considera-
tion of physical and clinical integration of specialist and general practitioner
units, development of team work and unification of all maternity services.

200. The gradual disappearance of separate general practitioner maternity units
is anticipated, and the view is expressed that a general practitioner obstetrician
should have had a minimum of six months post-registration experience in a
maternity unit approved for training. In view of the need to provide posts in
hospitals for post-graduate training of future consultants it is considered that the
numbers of general practitioners who will be allowed to work in hospitals may
have to be limited, and this opinion is linked with the expectation that with the
development of group practices only a minority of participating general prac-
titioners will wish to practise obstetrics. The consultant obstetrician must in-
evitably carry the overriding responsibility for all patients booked for delivery in
hospital irrespective of whether they are allocated to specialist or general
practitioner care. The general practitioner obstetrician should, however, have
available to him, in providing intranatal care for his patients in hospital, all the
facilities of the hospital including ancillary services such as radiology and path-
ology. The suggestion is made that selected general practitioner obstetricians
might be offered the opportunity to work in hospitals on a sesional basis.

201. Emphasis is laid upon the importance of examination and supervision of all
babies delivered in hospital, whether by specialists or general practitioners, by
the consultant paediatrician and his staff.

202. The Council agrees with the Department’s policy, in any new building pro-
gramme, of providing general practitioner beds as part of a fully equipped and
staffed maternity unit. In their view there is little to be said in favour of small
isolated general practitioner maternity units, and ideally the association of
general practitioner obstetric beds with fully equipped specialist units should be
as close as possible, both structurally and functionally. In particular it is desirable
to arrange for common delivery suites serving both general practitioner and
specialist beds.

203. In the long term, complete integration within the district general hospital
maternity unit is seen as the objective. Advantages would be the close contact
which general practitioner obstetricians would enjoy with other professional
members of the team in a working situation; the creation of training facilities, to
which the general practitioner would contribute, for pupil midwives and under-
graduates; and the staffing of general practitioner beds by midwives, nurses and
para-medical personnel currently involved in the care of maternity patients.

204. Recognising that it must be some time before fully equipped district general
hospitals are functioning in all areas, and that until then isolated general prac-
titioner maternity units may continue to exist, the Council offer the following
interim recommendations:

1. Each general practitioner obstetric unit should have attached to it at
least one consultant obstetrician and one consultant paediatrician; these
should have the overall supervisory responsibility for the unit and its
patients and pay regular visits.

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2. Each general practitioner maternity home should be linked with the
nearest or most conveniently situated specialist maternity unit, and the
functional linkage should be as close as possible. The parent hospital
should not only take over patients transferred on account of abnor-
mality but provide consultant and ‘flying squad’ cover. The general
practitioner unit might also look to the central sterile supply department
of the parent hospital for its equipment and instruments.

3. Only women specifically selected, in accordance with the now generally
accepted criteria, on grounds of probable obstetric normality should be
booked for delivery in the general practitioner home.

4. There should be set up a Booking Committee which might consist of the
matron, the consultant obstetrician, the Medical Officer of Health or his
deputy, and a representative of the general practitioner obstetricians.
This Committee should formulate policy with a view to ensuring as far
as possible that only the potentially normal patients are booked for
admission.

5. Every patient booked for delivery in the general practitioner home
should be seen at least once during the antenatal period by the con-
sultant obstetrician attached to the unit. It is desirable for him to hold
regular sessions during which he can not only carry out the routine
examination of all patients but also give an opinion upon any other
patients at the request of the general practitioners.

6. Every general practitioner unit should be equipped with apparatus for
the resuscitation of the newborn and all those practising obstetrics in the
unit, including senior midwives, should be familiar with the use of the
apparatus provided. Each baby born in the home should be examined at
least once by the paediatrician. The majority of consultant obstetricians
now accept this as routine practice in their own unit and it is not
unreasonable to ask general practitioner obstetricians to accept a similar
system, the value of which has been proven.

7. A staff committee, consisting of all the general practitioner obstetricians
using the home together with all the visiting consultants, should be
established and should meet regularly to decide policy. The chairman of
the committee should be elected from the members and could be either
a general practitioner or a consultant.

8. A standard method of keeping records should be established and an
annual medical report prepared and published.

Statement of Policy on the Maternity Service
(The Royal College of Midwives)

205. The Royal College believes that the hospital and domiciliary aspects of the
maternity service should be closely integrated, although they do not regard
unification under one or other of die three bodies involved in the present tri-
partite system as a practical possibility. In the College’s view, future unification
will depend upon the creation of a Maternity Service Committee as the employ-
ing authority for all midwives, but in the meantime integration should be sought
to the greatest possible extent.

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206. The Statement draws particular attention to the importance of the midwife’s
role. In relation to the care she should give after the birth no specific definition of
the “early postnatal period” is offered, but the view is expressed that flexibility
as to the day when the midwife hands over to the health visitor is desirable.

207. While the Statement does not express a view on the future pattern of
hospital bed provision, the importance of careful selection of cases for consultant
care is stressed, and the need for close association of general practitioner beds
with consultant obstetric units is recognised.

208. The continuance of an efficient domiciliary service both for those women
wishing to be confined at home and for properly planned “early discharge”
cases is visualized.

209. Much importance is attached to antenatal teaching in preparation for
childbirth and parenthood by professionally qualified staff. The idea is put
forward that some midwives might specialise in this kind of work.

210. The Statement expresses strong views on the future of midwifery training,
for admission to which a national education standard is advocated. The division
of training into two separate periods is thought to be out-dated, but importance
is attached to a sound knowledge of community care. It is suggested that the
content of the training syllabus should place greater emphasis upon neonatal
care, preparation for childbirth and parenthood, and the emotional needs of
women during pregnancy, labour and the puerperium.

211. In its concern with staffing the statement is confined to the existing tri-
partite structure and, in the hospital field, expresses support for the recommenda-
tions of the Salmon Committee. In particular that Committee’s concern with
access to management training is welcomed, and the College recognises that
“mixed” management courses attended by nursing and midwifery staff from the
present separate branches of the health services would make a substantial con-
tribution to the success of future integration.

212. The College’s Statement refers particularly to the importance of the non-
medical supervisor in the field of liaison with the hospital service. While there is
recognition that integration of services might necessitate revision of the qualifica-
tions for this post, the view is expressed that under the present arrangements
supervision of the midwifery service must remain separate from any co-ordina-
tion of the local authority’s nursing and midwifery services under a more senior
officer of special managerial ability, the non-medical supervisor remaining
directly responsible to the Medical Officer of Health.

Report of a Working Party on Obstetrics in General Practice
(Royal College of General Practitioners)

213. In common with other professional bodies concerned with the provision of
maternity services the Royal College’s Working Party have concluded that a
unified administrative structure would be welcomed although, like the Royal
College of Midwives, they express doubts as to the realism of considering such a
major change for a single section of the medical services. Effective and active
maternity liaison committees are seen as of great value in the transition towards
a unified service. The Working Party recognise that the proportion of deliveries
in hospital will continue to increase, and consider that early discharge schemes

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can no longer be regarded as a temporary expedient but should be carefully
planned to achieve true co-operation between all interested parties. In com-
mending continued availability of home delivery for mothers who desire it they
make important provisos concerning clinical suitability, home conditions and
the need to maintain efficiency in residual domiciliary services.

214. The future role of the general practitioner in the maternity service is seen as
an important one, not least from the point of view of providing a personal as well
as an efficient service to patients. The Working Party consider that as many
general practitioner obstetricians as possible, supported by teams including
midwives, home nurses, health visitors, etc., for work in the home, should also
have access to hospital beds and should co-operate closely with their specialist
colleagues. Extended employment of general practitioner obstetricians in the
hospital service to undertake normal obstetrics would, it is thought, release con-
sultants and their staff from routine care, and so improve teaching facilities;
with regard to the latter it is considered that general practitioner obstetricians
should play a part in the teaching of obstetrics.

215. Co-operation is the keynote of this Report, and the Working Party lay
stress upon the need for mutual respect and easy communication between general
practitioner obstetrician and consultant. A two-way flow of cases is visualised,
the general practitioner not only handing over to a consultant when complica-
tions become apparent but also resuming the care of patients who no longer
need a consultant’s attention. This sort of complementary service would be
facilitated by the closest possible integration of general practitioner and consult-
ant beds in hospital units, and the point is made that it is desirable for general
practitioner units to be near to specialist units so that specialist help is readily
available; ideally the two units should, if separate, be under the same roof.

216. Reference is made to the growing numbers of new entrants to general
practice who are qualified for admission to the obstetric list. The Report, how-
ever, emphasises the need for special vocational training in obstetrics, and
recommends the establishment of post-graduate teaching departments in each
region. For the future it is thought that admission to the obstetric list should be
restricted, eventually, to doctors with special training and continuing experience
in obstetrics, and the need to maintain standards, through an adequate amount
of obstetric work, is stressed. Here, as in other evidence received, the concentra-
tion of experience by specialisation within group practices is foreseen.

217. Brief reference is made above to training of the general practitioner
obstetrician, but the Working Party’s Report develops the questions of training
and qualification at some length, and we have noted above (paragraph 152) that
many Chairmen of Local Medical Committees endorsed the views of the Work-
ing Party. They recommend that undergraduate training should continue as at
present with emphasis on basic principles and that obstetrics should continue to
feature in qualifying examinations. To supplement basic training it is thought
that the vocational training already mentioned should consist of six months as a
house surgeon in a specialist maternity hospital during which the general
practitioner should spend some time in studying care and resuscitation of the
newborn, feeding problems and management of the premature baby. He should
also attend a gynaecological outpatient department weekly. Thereafter training

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would be completed by the conduct of general practice deliveries under super-
vision at home or in general practitioner units in hospital. For those practising
general practitioner obstetricians unable to work continuously in close associa-
tion with a specialist hospital it is suggested that provision should be made for
continuing education by way of residential and non-residential courses, for
clinical assistantships of an educational rather than service nature, and for short-
term exchanges between hospital doctors and general practitioners.

21 B. The Working Party have concerned themselves also with the special prob-
lems of provision of services in differing kinds of area, and conclude that a
standard pattern of service for all cannot be achieved. They express concern with
the special obstetric problems posed by differential birth rates, new towns, large
concentrations and scattered rural populations.

“The Non-Medical Supervisor of Midwives” — paper published by the Association
of Supervisors of Midwives

219. This paper reproduces the Midwives (Qualifications of Supervisors) Regu-
lations 1937 (S.R.O. 1937 No. 398), and sets out in detail both the practical
implications of the Midwives Act 1951 for non-medical supervisors and the
other, non-statutory functions which they may undertake.

220. Section I of the paper is concerned with supervision under the Midwives
Act 1951 within the area of the local supervising authority, but refers also to
duties under statutes (Notification of Births Act, Population Statistics Act,
Births and Deaths Registration Act, and Public Health Act 1936) other than the
Midwives Acts which do not stem directly from the statute with which the
Section purports to deal.

221 . Other Sections deal with Liaison Duties, Duties Regarding Drugs, Training
of Pupil Midwives and Other Duties of the Supervisor, all of them in the context
of the present structure of the maternity services, since the paper does not con-
cern itself with possible future developments.

222. The present liaison and other duties of non-medical supervisors set out in
the paper reflect the supportive role of the non-medical supervisor under the
present tripartite arrangements. Non-medical supervisors are almost invariably,
in addition to their statutory duties, responsible for superintending the domi-
ciliary midwifery services provided by their employing local health authorities,
and the burden of liaison with other branches of the service evidently falls
heavily upon them. The listed liaison duties suggest that the non-medical super-
visors may increasingly have assumed additional functions to meet the growing
need for maintenance of communications between local health authorities,
hospitals and general practice which the changing tripartite pattern has evoked,
particularly in the matter of planned early discharge.

First Report of the Joint Working Party on the Organisation of Medical Work in
Hospitals

223. Although the Working Party were concerned primarily with the hospital
situation, their Report discloses an awareness of the pressing need for improved
communications between hospitals and other members of the health services.
Their conclusion is that medical care is a single entity although it is provided from

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a complex of sources including hospital, general practitioner and community
services.

224. The Report suggests that obstetrics and gynaecology, inter alia, might be
combined to form a specialty group or “division” within the district general
hospital complex. Liaison activities of divisions would include organised con-
tacts with general practitioners and Medical Officers of Health.

225. In referring to inefficient use of beds arising from arrangements for emer-
gency admission the Working Party instance the way in which obstetric beds are
kept empty for patients who may be admitted in labour. They suggest that the
most important requirement is an agreed area plan for maternity work with a
recognised booking policy, well understood by hospital and home care services.

Report of the Royal Commission on Medical Education 1965-1968

226. So extensive and wide-ranging a Report cannot properly be epitomised in a
few words. The following paragraphs deal selectively with points of particular
interest within the context of our own terms of reference.

227. In their consideration of the future pattern of medical care the Royal
Commission have concluded that the general practitioner will continue to be the
first person to whom the patient will turn for advice. Organisation of general
practice will, however, continue to change and a steady trend towards the forma-
tion of group practices based on proper premises, good equipment and well
trained and organised staff is foreseen, the most obvious and natural setting for
which is the health centre. The likelihood that there will be much reliance, within
group practices, on functional specialisation by individual doctors accords
closely with the views expressed by Chairmen of Local Medical Committees.

228. In common with most observers of the health services as a whole, the Royal
Commission note a steady movement towards integration of hospital, general
practitioner and local authority services, and they envisage the replacement of
present medical categorisation by a broad structure of vocational specialties.
Much of the Report is concerned with the changes in medical education which
such development will necessitate.

229. With special reference to undergraduate training in obstetrics, gynaecology
and paediatrics, it is considered that a period of residence in a maternity unit
should be retained to enable students to get a proper appraisal of practical
obstetrics. Stress is laid upon the need for thorough grounding in the principles
of antenatal and postnatal care ; and it is considered that the student should learn
something of preparation for childbirth and parenthood, the general principles
of human reproduction and the psychological aspects of childbearing. Practical
experience of abnormal obstetrics is seen as more properly to be acquired after
registration. It is thought also that students should be taught the problems of
fertility and infertility and that there should be a family planning clinic and a
Department of Paediatrics in every teaching unit. In connection with the latter,
there is mention of the need for teaching on the newborn in the maternity unit,
including instruction on foetal development and growth, management of the
normal and premature infant, infant feeding and the diseases and disorders of
the newborn.

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230. Recognising the need both to bring into closer relationship training for
general practice and other fields and training for hospital specialties, and to
remove the dissatisfaction of young doctors about the diffusion of information
concerning careers and appropriate preparation, the Royal Commission propose
a new pattern of professional training. This would, in brief, comprise four stages :
(a) an intern year; (b) general professional training lasting about three years;
(c) further professional training; and (d) continuing education and training for
all doctors in career posts. The aim would be to extend and reorganise post-
graduate medical education so as to provide a systematic and rational progress
from basic qualification to the appropriate level of career competence and to
maintain that competence thereafter. In the field of general practice the sugges-
tion is put forward that within the three year’s general professional training a
six-month appointment in obstetrics and gynaecology would be highly desirable.

Report by a Committee of the Scottish Health Services Council — The Staffing of
the Midwifery Services in Scotland

231. This Report was published in 1965, and shows that by as early as 1963 the
trends in hospital and domiciliary confinement rates which have given rise to this
Sub-Committee’s existence were already well advanced in Scotland. The Scottish
Committee were primarily concerned with midwifery recruitment, training, work
and establishments, and with the optimum use of skills, in both the hospital and
the domiciliary services. They were assisted in their deliberations by the results
of a work-study carried out by the Scottish Home and Health Department.

232. The Scottish Committee were persuaded that although for the time being
domiciliary services should remain in the hands of local authorities, in the long
run the decline in domiciliary confinements coupled with an increase in the
amount of domiciliary postnatal care might lead urban authorities to decide to
give up direct employment of midwives and ask the hospital authorities to pro-
vide a domiciliary service on their behalf. Other possibilities such as a reduction
in midwifery staff and employment of part-time midwives to give postnatal care,
or combination of the midwifery with the health visiting and home nursing
services, were considered but thought likely to be less satisfactory, and it was
suggested that experiments might be tried in suitable areas to find out how best
to overcome the various problems involved in hospital provision of all midwifery
services.

233. In the rural areas difficulties in such an arrangement were thought likely to
be much greater, largely because in these areas midwifery was combined with
district nursing and health visiting, services which hospitals could not undertake.
This problem is, in fact, particularly acute in Scotland where doubly and triply
qualified nursing personnel are extensively employed by local authorities.

234. The Scottish Committee concluded that regardless of the outcome of the
suggested experiments positive efforts should be made to secure co-operation
between the hospital and domiciliary services. They saw not merely co-operation,
but complete integration of maternity services as a desirable, if not immediately
attainable, objective.

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CHAPTER IX

DISCUSSION

235. We have been aware from the outset that, notwithstanding our terms of
reference, the questions of domiciliary midwifery and hospital bed needs cannot
be isolated from the maternity services as a whole. In seeking evidence we have
not thought ourselves restricted to a narrow field, and the foregoing chapter has
ranged sufficiently widely over the services as a whole to enable us to relate
domiciliary midwifery and hospital bed needs to other aspects ; while maintaining
this perspective we have not, however, set out to study the maternity services
exhaustively, as the Cranbrook Committee did. It may be convenient, in con-
sidering this evidence, to deal with it in the sequence in which the needs of the
mother and baby arise. Some overlapping is inevitable in reviewing a service in
which at present the division of responsibilities is by no means clear cut, and
which offers alternative facilities at several points.

Medical and midwifery maternity services

236. Whatever the future role of the general practitioner in the maternity
services may be he is at present, and is likely to remain, the first point of contact
of an expectant mother with the National Health Service. It is therefore import-
ant that all general practitioners, whether or not they will continue to provide
care throughout pregnancy, should be equipped not merely to diagnose preg-
nancy and some of its more common early complications but also to offer
informed advice to the expectant mother on the services available to her. The
Royal Commission on Medical Education recommended that all general
practitioners should, within their general professional training, hold a six-month
appointment in obstetrics and gynaecology. Because a medical practitioner may
at any time, be called upon to treat pregnant women a sound basic knowledge is
obviously desirable, and we consider that all general practitioners should have
some training in obstetrics and gynaecology during their period of professional
training. This is particularly important if the period of time available for
obstetric and gynaecological teaching in the undergraduate curriculum is further
reduced, as seems likely if the recommendations of the Royal Commission con-
cerning the clinical period of training are accepted. However, we doubt whether
it is either practicable or necessary for those general practitioners not intending
to practise obstetrics to hold a six months resident appointment in an obstetric
department.

237. The Royal College of General Practitioners’ Working Party, throughout
their report, use the term “general practitioner obstetrician” a description
implying the possession of special skills. While we think it right that all general
practitioners should have some basic training in obstetrics and gynaecology, we
do not think that general practitioners should undertake maternity work, except
in emergencies, unless they qualify for admission to the obstetric list. Many
Chairmen of Local Medical Committees endorsed this view; The Royal College

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of General Practitioners’ Working Party foresaw a restriction of admission to
the obstetric list to doctors with special training and continuing experience, and
emphasised the need to maintain standards. Specialisation within group prac-
tices emerges from the evidence as the most likely factor to influence the contri-
bution that will be made by general practitioners to the maternity service, and we
would expect the development of health centres further to accelerate this. The
proportion of maternity medical services provided by general practitioners not
on the obstetric list is small (they represented only about 2 \ per cent of all claims
paid in 1967).

238. At an early stage in pregnancy the expectant mother may at present be
receiving advice from her general practitioner, from the domiciliary midwife at
home or at a local authority clinic and may also have been referred to a con-
sultant obstetrician who will see her as necessary in a hospital clinic. While each
branch of the maternity services has an important part to play, the division of
responsibilities under the present tripartite system of administration runs a risk
of overlapping and possibly failure of communications to the patient’s dis-
advantage.

239. The Cranbrook Committee took full note of the overlapping of services
which existed at the time of their report, and of the need for a greater degree of
planned co-ordination. They recommended that Maternity Liaison Committees
should be set up, but the evidence of Senior Administrative Medical Officers
suggests that their effectiveness varies from region to region. We consider that
these Committees, because of their professional membership, should play an
even greater part in bringing the various branches of the service closer. The
evidence we have received suggests that a stage has now been reached when
integration should begin to replace co-ordination.

240. Although the majority of confinements take place in hospital the period of
labour itself represents a very small proportion of the total time during which
any particular patient has need of maternity services. Before this stage is reached,
as has already been indicated, all three branches share in the provision of care,
and it may be appropriate at this point to consider the factors currently influenc-
ing the ways in which care is given.

241. The evidence from Medical Officers of Health suggests that there is less
difficulty in recruiting domiciliary midwives than in redeploying those in post to
put them to the best use. These midwives not only provide antenatal care but, in
some areas where establishments have been related to exceptionally high hospital
confinement rates, may be heavily engaged in postnatal care of cases discharged
early from hospital. Thus while domiciliary midwives continue to contribute
very substantially to both antenatal and postnatal care, their work lacks the
continuity which may well have been one of the more attractive features of their
profession in the past.

242. Payments to general practitioners for part maternity services have increased
considerably over the last five years or so, although those for complete services
have decreased. General practitioners are concerned at some stage in the care of
most pregnant women and are sharing more and more in the provision of care
with hospitals.

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243. It is essential that those concerned with the delivery should have full details
of the antenatal history. The Cranbrook Committee thought that the respon-
sibility for ensuring that antenatal care is provided should be placed on the
general practitioner obstetrician but in present circumstances the latter, like the
domiciliary midwife, is less than ever providing complete personal service, in-
cluding the conduct of labour. Continuity of care is a question raised several
times in evidence, and such a concept is indisputably a good one. We are con-
cerned, however, that it should not be construed narrowly as a continuous
personal relationship between the patient and only one midwife or doctor.
Modem organisational trends, such as the creation of health centres, the setting
up of group practices and the introduction of off-duty rotas are making this
interpretation less and less appropriate.

244. In our view continuity of care calls for efficient sharing of information
between those providing maternity care. The fewer concerned in any individual
patient’s care the more efficiently communications can be made. Communica-
tions are not facilitated by the present organisational division of the midwifery
profession into hospital and domiciliary midwives.

245. We therefore conclude that one of the first steps towards rational provision
of maternity care should be the unification of the midwifery service under a
single authority. Both the Central Midwives Board and the Royal College of
Midwives have approved the principle of unification of the midwifery service,
but we are aware that the Royal College of Midwives and the Royal College of
General Practitioners have reservations about the type of authority which should
administer a unified service. The Central Midwives Board consider that domi-
ciliary midwifery could in areas where integration is possible, be administered by
hospital authorities provided that staffing problems could be overcome. The law
has since 1948 permitted local health authorities to make arrangements with
hospital authorities for the provision of domiciliary midwifery and where
practicable we think this should be encouraged as an interim measure. It will be
necessary for well-defined catchment areas to be agreed between hospitals and
local health authorities. If employed by hospital authorities, present domiciliary
midwives would still be free to live where they chose, would retain their interest
and participation in domiciliary work, and the nature of their work, either in or
out of hospital, could be planned to suit the wishes of the individual midwife as
well as the needs of the service. We see the extension of such arrangements,
where practical and locally acceptable, as the least traumatic means by which the
unification of the midwifery service might be approached.

246. Under such arrangements midwives would take part in antenatal care
whether provided in the home, health centres, general practitioners’ surgeries, or
hospital clinics, and all midwifery records would be consolidated. It is, of course,
envisaged that domiciliary service in rural areas would need to be provided by
midwives situated, in relation to the pattern of group practices and health
centres, to meet local needs. The district nurse/midwife must be encouraged to
continue midwifery duties, if, and when, the midwifery service is unified. All
domiciliary midwives would, however, benefit by having closer contact with
hospital midwifery and by becoming an integral part of the obstetric team.

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247. With a unified midwifery service co-operation with general practitioner
obstetricians should be easier. We are in favour of greater participation by
general practitioners in hospital maternity work, and we wish to see general
practitioner/consultant obstetrician teams combining to provide medical care.
The facilities of hospital clinics and health centres, staffed by midwives under a
single administration, supplemented where necessary by general practitioner/
midwife clinics, should provide a fully adequate service; and the reality of team
working should in our view provide truer continuity of care than can at present be
achieved. Continuity of care is disrupted when local health authority doctors,
who are concerned only with the antenatal and postnatal periods, participate in
the service; general practitioner obstetricians are much better fitted to undertake
this work, and should be encouraged to do so.

248. We consider that the greater safety of hospital confinement for mother and
child justifies the objective of providing sufficient hospital facilities for every
woman who desires or needs to have a hospital confinement. Even without
specific policy direction the institutional confinement rate has risen from 64*6
per cent in 1957 to 80*7 per cent in 1968, and shows every sign of continuing to
rise, so that discussion of the advantages and disadvantages of home or hospital
confinement is in one sense academic.

249. Only a minority of women choose home confinement but we accept the
view of the Royal College of Midwives and Chairmen of Local Medical Com-
mittees that wishes for home confinement should be respected provided, of
course, that there are no medical or social contra-indications. In this connection
early assessment in social cases, and as soon as possible in medical cases, is
important and we share the opinion of Chairmen of Local Medical Committees
and others who advocate that at the present time every woman should be seen
by a consultant obstetrician at least twice during pregnancy.

250. Medical care of women confined at home should, as we have already
suggested, be the responsibility of general practitioners with special training and
actively engaged in the practice of obstetrics. We have no wish, however, to see
perpetuated a distinctively general practitioner-orientated branch of the maternity
services. The desirability of general practitioner/consultant obstetrician team
working has already been touched upon, and we think that this would encourage
the provision of an integrated service to patients. The more direct the contact of
the general practitioner obstetrician with his consultant colleagues the more
readily he will call upon hospital facilities for his patients for whom home con-
finements are planned when abnormalities arise.

251. What we have said in paragraphs 245 and 246 above about unification of
midwifery services has obvious implications for midwifery care of women con-
fined at home. The need to maintain midwifery skills, particularly the conduct
of labour, by practice featured in the evidence of both Medical Officers of Health
and Chairmen of Local Medical Committees. The Central Midwives Board
considered that the skills of midwives allowed to conduct confinements solely
in a diminishing domiciliary field could be maintained by suitable refresher
courses. The gaining of additional practice would also be facilitated if midwives
undertaking this work could, from time to time, work with their hospital
colleagues. The extension of arrangements under which hospital authorities
provided a domiciliary service as agents of local health authorities would make

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this easier to achieve, and recent changes in the law permit domiciliary midwives
to work in hospitals. A majority of Chairmen of Local Medical Committees
were in favour of this, and both in their evidence and that of Senior Administra-
tive Medical Officers the suggestion of a hospital/domiciliary midwifery rota
was advanced. We are in favour of this, but realize that there are practical
difficulties at present. The view of some Senior Administrative Medical Officers
that future domiciliary midwifery might be concerned almost entirely with
patients discharged early appears to assume a continued separate existence for
this branch of the service, and would have less relevance under a unified service.
Both they and the Royal College of Midwives have suggested that some mid-
wives might specialise in particular aspects, and the evidence makes it clear that
specialisation is already a feature of hospital midwifery. We share the Central
Midwives Board’s view that any specialist training should follow full basic
training.

252. We consider that the trend towards centralisation in district general
hospitals may for some time require modification to meet local needs as far as
maternity services are concerned. Home confinements in rural areas will con-
tinue to present special problems and for the time being midwives serving these
areas will need to be situated locally. Unforeseen need for hospitalisation or
immediate consultant attention in such cases must be met, and some review of
the existing emergency obstetric services may be needed. Chairmen of Local
Medical Committees, Senior Administrative Medical Officers and the Royal
College of General Practitioners all expressed concern about the problems of
rural areas, and we think that the long term solution should be the provision of
hostel beds to enable admission of women to hospital before labour commences.

253. There will be a continuing need for general practitioner obstetricians and
midwives to work closely together in providing care for women confined at home.
Chairmen of Local Medical Committees commended attachment schemes, but
the present concept of attachment is not wholly consistent with their view that
domiciliary midwives should be employed in hospitals. We must emphasise that
full co-operation is best achieved on the lines suggested in paragraphs 243 to 247
above, and that individual attachment of midwives should be replaced by
continuity of association of particular groups of midwives with particular
practices, based where possible in health centres or group practices.

254. Support for continued provision of separate general practitioner obstetric
units came mainly from Chairmen of Local Medical Committees, with the
qualification that proper equipment and ready access to consultant cover should
be available. Evidence from Senior Administrative Medical Officers, however,
showed that a very large proportion of general practitioner beds are in com-
pletely separate units too remote from consultant units to satisfy this qualifi-
cation. We consider that admission to separate general practitioner units must
be restricted to normal cases. Both the Royal College of General Practitioners
and the Royal College of Obstetricians and Gynaecologists favour integration
of general practitioner and consultant beds under one roof. We agree with this,
and consider that small isolated general practioner units should be replaced as
soon as possible by larger combined consultant and general practitioner units
in general hospitals. We recognise that for some time to come the retention of some
separate general practitioner units will be necessary to maintain a service; while
they continue to exist it is essential that their links with consultant units should

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be very much closer than they are at present and there should be officially
appointed obstetricians and paediatricians. As with women confined at home,
patients in these units should have access to all the facilities which a modern
maternity service can provide. We would expect midwives working in the com-
munity to help in the staffing of these units, since they will, with the general
practitioner obstetricians, have shared in the antenatal care of the patients
concerned.

255. We are not convinced that in the isolated general-practitioner maternity
unit either the on-call rota system or the system of notification of the general
practitioner concerned when his patient is in labour, alternatives suggested by
Chairmen of Local Medical Committees, can provide complete medical cover.
In combined consultant/general practitioner units we would envisage no insur-
mountable problems, assuming that a good working relationship between
general practitioners and hospital medical staff has been established. Indeed, we
hope that either by the appointment of general practitioners as clinical assist-
ants, or by other means, general practitioners would share in the work of the
unit in co-operation with consultant obstetricians. In the present isolated
general practitioner maternity units it must ultimately be for the hospital
authorities to ensure that medical cover and equipment is adequate, and we have
little doubt that the financial and other implications of providing satisfactory
cover will influence them in decisions as to retention of these units. The future
status of general practitioner obstetricians in a hospital-orientated maternity
service may depend largely upon the extent to which they demonstrate that they
wish to be involved.

256. An increase in midwifery staff was envisaged by Senior Administrative
Medical Officers as a consequence of any increase in hospital confinements, but
this was in the context of the present divided service. It is to be hoped that a move
towards the unification of midwifery might lead to a more rational deployment
of midwives. Although unification of midwifery might contribute to the removal
of some of the disincentives to the recruitment of midwives which Senior
Administrative Medical Officers reported, others may be less easy to deal with.

257. Staffing of small maternity units is extravagent. We therefore regard it as
important that some priority should be given to the abolition of small maternity
units and the provision of modern facilities, both for patients and staff, in new,
well-sited buildings. Both Senior Administrative Medical Officers and Chairmen
of Local Medical Committees suggested that ancillary staff should be employed
to relieve midwives of work not requiring their skills, and we think that this
practice should be extended. The part-time employment of married midwives
should be encouraged.

Bed needs

258. We have said sufficient above to indicate our main views on the provision
of medical and midwifery cover in hospital. We now turn to particular aspects
of the hospital maternity service, including bed needs.

259. The papers which we commissioned have persuaded us that statistical
methods are of great value. While in broad terms we consider, for example, that
with a birth rate of 17 per 1,000 population, with 25 % of beds used for antenatal
care, a six day average postnatal stay, and a 75 % occupancy of lying-in beds,

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something of the order of 0-5 beds per 1,000 population would allow 100%
hospital confinement, we do not think that this sort of prediction can be used
indiscriminately. We consider that all regional planning of maternity bed pro-
vision should, subject to local adaption, be based upon statistical techniques
related to relevant factors. The birth rate itself may be difficult to predict until
the full effects of family planning provision and abortion become evident.

260. The proportion of maternity beds set aside for antenatal care has shown a
slight rise in the last decade. This trend may reflect the growing recognition of
the importance of in-patient antenatal treatment, and it would seem prudent not
to anticipate any reduction in the percentage of beds required for antenatal care,
at present on average about 25 % of all maternity beds. Precise future needs for
antenatal beds are difficult to predict. The provision of antenatal beds should be
related statistically to the births in the area served having regard to the health of
the community and its social character.

261. In considering the paper on maternity bed needs (Appendix I) it became
evident that the duration of postnatal stay was the factor most likely to influence
the number of beds needed to accommodate a given percentage of all births in
hospital. If the hospital confinement rate may ultimately reach almost 100 %, the
possibility of further reduction in the average length of postnatal stay may be of
great importance in planning. Averages in this context are determined by the
decisions of obstetric teams in particular cases, and it is no part of our brief to
encroach upon medical judgement. We observe, however, that the average
length of postnatal stay has fallen steadily over several years, and we regard it
as important that those planning maternity bed provision should be continually
aware of trends of this kind.

262. A majority of Senior Administrative Medical Officers, in their evidence,
implied that additional beds would be needed to meet all requests for hospital
confinement. Statistical analysis suggests, however, that for the country as a
whole the overall number of additional beds needed in the next few years to
permit a further substantial rise in the hospital confinement rate may not be
great. However, many of them are at present sited in unsuitable accommodation
and wrongly distributed.

263. Integration of consultant and general practitioner beds would contribute
to greater flexibility in meeting demands, as well as to team working. Flexibility
in the use of hospital beds may in fact be a very important prerequisite of econ-
omical planning, and in a service like the maternity service for which demand
fluctuates seasonally there would be considerable advantage in having access to
other beds at times of peak pressure. We therefore suggest that in planning
maternity units thought should be given to the possibility of siting them close to
other beds the use of which could be varied without detriment to other patients
in less immediate need of hospital care.

264. It has already been observed that adequate delivery suite facilities may be
of prime importance, and we see no room for economies here. As with lying-in
beds, delivery suites should be shared by consultants and general practitioner
obstetricians.

265. Not all delivery suites are housed in modern buildings, and the time
needed, for example, for cleaning, airing and redecorating may be greater in old

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premises. Modification of statistically assessed requirements may be needed in
the light of local circumstances.

266. At times of peak pressure, antenatal and lying-in patients may be accom-
modated temporarily in other hospital beds, but it is essential to provide suffici-
ent delivery suite facilities to meet all contingencies. The increased work at
times of great pressure will also have its repercussions on ancillary services, and
it is necessary for all departments involved in providing maternity services to
have the resources to meet maximum demands.

267. Over and above the need for planning which takes account of periods of
peak pressure, contingencies such as temporary or complete closure of a unit
because of an outbreak of infection, or for staffing or other reasons, need to be
provided for.

Postnatal care

268. Average length of postnatal stay has already been mentioned without
considering the extremes, which range from more than 10 days to 48 hours or
less. It is to the latter that we shall refer as “early discharges”, notwithstanding
the definition, closely linked with that of the “lying-in period” for the purposes
of the Midwives Rules, employed in connection with local health authority
statistical returns. These refer to all discharges before the 10th day as early, a
concept which appears to bear little relation to current practice, since as many as
72 / of the cases visited by domiciliary midwives during the three months July-
September 1967 were reported by Medical Officers of Health to have been dis-
charged after 7 days or less.

269. The evidence of both Medical Officers of Health and Senior Administra-
tive Medical Officers confirmed that early discharges had affected the deploy-
j.nvDt of midwives. Postnatal care of such cases takes up an increasing propor-
tion of the time of domiciliary midwives, and the pattern of work of hospital
midwives has also been changed, not always to their greater satisfaction. The
practice, and its further extension, is nevertheless regarded as inevitable, and
we do not propose either to endorse or to condemn it; it evidently meets the
wishes of many mothers. We think however that, so long as the mi dwifery service
remains divided, more could be done to ensure continuity of care, and that there
is a need for much closer, systematic liaison between hospitals and local health
authorities, based perhaps on national standard procedures. If hospitals pro-
vided a domiciliary midwifery service some of the problems would disappear,
but there will be a continuing need for liaison to ensure the provision of sup-
portive services such as home helps and to link appropriately with the health
visitor. We consider that whether early discharge is practised or not, definite
arrangements should be made for the re-admission of mother and baby to the
hospital whenever this becomes necessary for either of them.

P a ^i cu l ar aspect of postnatal care is the “early postnatal period” to
which the Royal College of Midwives referred in their statement of policy, and
we agree that there should be no hard and fast rule as to the day when the mid-
wife hands over responsibility to the health visitor. The Royal College of Mid-
wives were concerned to ensure that a midwife attended for at least 10 days and
t0 28 days if necessary. We understand that at present some women dis-
charged from hospital between 6 and 10 days after delivery receive their first

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visit from a health visitor if a midwife is not available. In our view there should
be flexibility to meet the needs of each mother and baby, and well organised
channels of communication between hospital and community services will be
necessary to ensure this.

271. Although doctors and midwives have always been concerned with the
survival and care of the newborn child, this aspect of the maternity services has
not received systematic attention and the Cranbrook Committee did not men-
tion it in their review. Recent developments in ante- and intra-partum care and
in resuscitation have shown the possibility of improving the chances of infant
survival, and the implications of this for the maternity and paediatric services of
the future was one of the reasons underlying the setting up of this Sub-Com-
mittee.

272. The immediate postnatal care of every infant, wherever it is born, should
include a full clinical examination either by a consultant paediatrician or by a
doctor who should be trained and experienced in the detection of deviations
from normal development which call for urgent attention or for surveillance.

273. We consider that family planning, which includes spacing as well as
limitation, should be an integral part of the maternity service. Obstetricians,
general practitioners and midwives should be conversant with modern techniques,
and should take the opportunity afforded by antenatal visits to discuss, as early
as possible, future family intentions with their patients. The present division of
the maternity services and the fragmentation of family planning facilities make
it difficult to ensure that patients who are referred to another agency take
advantage of the arrangements made for them. The increasing proportion of
births taking place in hospital suggests that this could in future be a focal point
for the family planning service, linked to the maternity service. Advice, which in
selected cases would include the offer of sterilisation, would then be available
in the early postnatal period before the patient left hospital. The Sub-Com-
mittee consider that family planning is of such importance that it should be
provided free as part of any maternity service.

Supervision

274. The part played by the non-medical supervisor of midwives in liaison
between hospital and local health authority services was mentioned several
times in evidence and it may be appropriate here to consider her future role.
We agree with the Royal College of Midwives that a revision of the qualifica-
tions for appointment of the non-medical supervisor may be needed and fully
accept that there is a distinction between statutory supervision and the
managing of the service. Indeed, revision of the Midwives Acts and subsidiary
legislation generally as the Central Midwives Board have suggested, may be
necessary in the light of the many changes in the practice of midwifery which
have occurred since regulation and supervision of the profession first became
the subject of enactment.

275. Any reconsideration of the non-medical supervisor’s role in a unified
service will have to embrace the question of who should employ her and how she
should fulfil her respective supervising and managing functions. It is not, how-
ever, within our terms of reference to advise which, if any, authority should be
responsible for supervision and we therefore merely observe that this question
needs careful reconsideration.

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CHAPTER X

CONCLUSIONS AND RECOMMENDATIONS

276. The views which we have expressed in the preceding chapter stem largely
from evidence related to the divided structure of the National Health Service in
which the maternity services operate. We see unification of the maternity services
as the ultimate goal.

277. We consider that the resources of modern medicine should be available to
all mothers and babies, and we think that sufficient facilities should be provided
to allow for 100% hospital delivery. The greater safety of hospital confinement
for mother and child justifies this objective.

278. The district general hospital will be the obvious focus for all maternity
services, both hospital and domiciliary, in the area served by it. District general
hospitals should have close links with health centres.

279. The divisional organisation of obstetrics and gynaecology, with the
inclusion of neonatal paediatrics, is welcomed.

280. Medical and midwifery care should be provided by consultants, general
practitioners and midwives working as teams.

281. Chairmen of hospital divisions should be responsible, with the community
physician, for co-ordination of the hospital and community services needed by
mothers and their families.

282. The unification of maternity services implies the employment of all mid-
wives by a single authority directly responsible for the provision of all midwifery
services. In such circumstances the present division of the midwifery profession
would disappear, and we would welcome this.

283. Small isolated obstetric units should be replaced by larger combined con-
sultant and general practitioner units in general hospitals. In the latter units all
beds and facilities should be shared.

284. We recognise that the full implementation of our long-term recommend-
ations might involve substantial additional cost and that it may not be possible
to introduce them all quickly in present economic circumstances.

285. Without complete unification of the health service administrative changes
can be only of a limited nature. We" have therefore suggested changes which
should be adopted as interim measures pending full unification. A summary of
these recommendations, which should be read in the context of the cited para-
graphs, is set out below:

Interim Recommendations

(d) Midwifery Services

(i) As a first step towards unification local health authorities should

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be encouraged to make arrangements with hospital authorities for
the provision by the latter of domiciliary midwifery services.
Preliminary agreement on well-defined catchment areas will
facilitate this. (245, 246).

(ii) Midwifery services for home confinement in rural areas should,
for the present, be provided by locally housed midwives until it is
possible, by providing hostel beds, to arrange for women in these
areas to be admitted, before the onset of labour, for hospital
confinement. (252).

(iii) Continuity of patient care is best achieved by continuity of
association of particular groups of midwives with particular
general practices, based where possible in group practices or
health centres. (253).

(iv) Priority should be given to the improvement of facilities in matern-
ity units and working conditions of midwives. (256-257).

(v) The practice of employing ancillary staff to relieve midwives of
work not requiring their skills should be extended. (257).

(vi) In relation to the “early postnatal period” there should be no
hard and fast rule as to the day when the midwife’s responsibility
for her patient ends, or as to the day when the health visitor makes
her first visit. (270).

(vii) There is a need for revision of the Midwives Acts and subsidiary
legislation, particularly that relating to supervision of midwives,
in the light of the many changes which have occurred since regu-
lation and supervision of the profession first became the subject
of enactment. (274).

( b ) Bed needs

(i) The regional planning of maternity bed provision should, subject
to local adaptation, be based upon statistical techniques related
to relevant factors. (259).

(ii) The proportion of beds used for antenatal care should not be less
than 25 % of all maternity beds. (260).

(iii) Those planning maternity bed provision should be continually
aware of trends such as the reduction in the average duration of
postnatal stay. (261).

(iv) The possibility of siting maternity units close to other beds which
could be brought into use for obstetrics at times of pressure
should be considered. (263).

(c) The Obstetric Team

(i) All general practitioners should have some training in obstetrics
and gynaecology during their period of professional training.
(236).

(ii) General practitioners who do not qualify for admission to the
obstetric list should not undertake maternity work. (237).

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(iii) General practitioner obstetricians should provide all the antenatal
and postnatal care at present given by local health authority
doctors. (247).

(iv) At the present time every woman should be seen by a consultant
obstetrician at least twice during pregnancy. (249).

(v) Admission to general practitioner units must be restricted to
normal cases. (254).

(vi) The links between separate general practitioner units and con-
sultant units need to be improved. (254).

(vii) Either by the appointment of general practitioners as clinical
assistants, or by other means, general practitioners should share
in the work of combined units below consultant level in co-
operation with the consultant obstetrician. (255).

(d) General

(i) There will be a continuing need for liaison, particularly in early
discharged cases, between hospitals and local health authorities to
ensure the provision of supportive services such as home helps, and
to link appropriately with the health visitor; while midwifery
remains divided national standard procedures for early discharge
might facilitate continuity of care. (269). Maternity Liaison
Committees should play a greater part in bringing the various
branches of the service closer. (239).

(ii) Whether early discharge is practised or not, definite arrangements
should be made for readmission of mother and baby to hospital
where necessary. (269).

(iii) Immediate postnatal care of every infant, wherever it is born,
should include a full clinical examination by a doctor trained and
experienced in the detection of deviations from normal develop-
ment. (272).

(iv) Family planning should be an integral part of the maternity
service, and it should be provided without charge. (273).

286. The changes in professional thought and the administrative action which,
it is recommended in this report, should flow from it, must be associated with a
change of community attitudes towards midwifery and maternity matters. To a
great extent we look upon this educational responsibility as being one for the
professions concerned. The obstetric team, which we have indicated as necessary
for the service itself should include amongst its responsibilities the education of
the community to the desirability and benefits of the reorganisation. It is ex-
pected that in this they will draw on the experience of the community physician
and his staff.

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REFERENCES

Abortion Act, 1967. London, H.M.S.O. (paragraphs 14 and 32).

Arthurton, M. W. and Bamford, F. N., 1967. British Medical Journal, iii, 517 (para-
graphs 112 and 124).

Association of Supervisors of Midwives, (1968). The non-medical supervisors of mid-
wives. Cheam, Association of Supervisors of Midwives (paragraph 219).

Butler, N. R. and Bonham, D. G., 1963. Perinatal Mortality. The first report of the 1958
British Perinatal Mortality Survey. Edinburgh and London, Livingstone (paragraphs
27 and 83).

Central Health Services Council, 1961. Human relations in obstetrics: report of the
Standing Maternity and Midwifery Advisory Committee. London, H.M.S.O. (para-
graph 44).

Central Health Services Council, 1961. Prevention of prematurity and the care of prema-
ture infants: report of the Joint Sub-Committee of the Standing Maternity and Mid-
wifery Advisory Committee and the Standing Medical Advisory Committee ( Chairman :
Sir Andrew Claye. London, H.M.S.O. (paragraph 125).

Central Health Services Council, 1968. Relieving nurses of non-nursing duties in general
and maternity hospitals: report of the Sub-Committee of the Standing Nursing
Advisory Committee (Chairman: Miss M. I. Farrer). London, H.M.S.O. (paragraph
59)

Clarke, C. A., 1968. British Medical Bulletin, 24, 3 (paragraph 121).

Clarke, C. A. et al 1958 International Archives of Allergy and Applied Immunology, 13,
5 (paragraph 121).

Committee on Local Authority and Allied Personal Social Services, 1968. Report.
(Chairman: F. Seebohm) (Cmnd. 3703). London, H.M.S.O. (paragraph 11)

Craig, G. A. and Muirhead, J. M. B., 1967. British Medical Journal, iii, 520 (paragraph

111 ).

Golding, A. M. B., 1967. Lancet i, 565. (paragraph 110).

Health Services and Public Health Act, 1968, London H.M.S.O. (paragraphs 16, 48,
147 and Appendix A).

Heilman, L. M., Kohn, S. G. and Palmer, J., 1962. Lancet , i, 227 (paragraph 124).

Hudson, C. K., 1968. Practitioner, 201, 816 (Appendix D)

Law, R. G,, 1967. Standards of obstetric care. Edinburgh and London, Livingstone
(paragraph 28).

Marshall, F. M., 1967. Lancet, i, 678 (paragraph 109).

McEwan, E. D., 1964 Lancet, ii, 744 (paragraph 124).

McEwan, E. D., 1967. Lancet, i, 489 (paragraph 108)

Ministry of Health, 1956. Report of the Committee of Enquiry into the Cost of the
National Health Service. (Chairman: C. W. Guillebaud), (Cmnd. 9663). London,
H.M.S.O. (paragraphs 19 and 35).

Ministry of Health, 1957-1969. Report(s ) on the confidential enquiries into maternal
deaths in England and Wales for the years 1952-54, 1955-57, 1958-60, 1961-63 and
1964-66. (Reports on Public Health and Medical Subjects, 97, 103, 108, 115, 119).
London, H.M.S.O. (paragraphs 28, 86 and 113).

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Ministry of Health, l£&rffceport of the Maternity Services Committee . (Chairman: The
Earl of Cranbrookk London, H.M.S.O. (paragraphs 6, 20, 33, 51, 60, 77, 92, 105, 235,
271).

Ministry of Health, 1960. Maternity medical services (E.C.L. 81/60), London, Ministry
of Health (paragraph 69).

Ministry of Health, 1965. On the state of the public health. Annual report of the Chief
Medical Officer for the year 1965. London, H.M.S.O., p.99 (paragraph 86).

Ministry of Health, 1965. The planning of early discharge schemes for maternity
patients. (Issued with H.M. (65/32), London, Ministry of Health (paragraph 22).

Ministry of Health and Scottish Home and Health Department, 1966. Report of the
Committee on Senior Nursing Staff Structure. (Chairman: B. Salmon). London,
H.M.S.O. (paragraph 58).

Ministry of Health, 1967. First Report of the Joint Working Party on the Organisation
of Medical Work in Hospitals. (Chairman: Sir G. Godber). London, H.M.S.O.
(paragraphs 13, 98 and 223-225).

National Board for Prices and Incomes, 1968. Pay of nurses and midwives in the
National Health Service. Report No. 60. (Cmnd. 3585). London, H.M.S.O. (para-
graph 12).

National Health Service Act, 1946. London, H.M.S.O. (paragraphs 18, 48, 147 and
Appendix B).

National Health Service (Family Planning) Act, 1967. London, H.M.S.O. (paragraphs
15 and 32).

Oldershaw, K. L. and Brudenall, J. M., 1968. British Medical Journal, iii, 112 (para-
graph 77 and Appendix Q.

Pinker, G. D. and Fraser, A. C, 1964. British Medical Journal, ii, 99 (paragraph 124).

Rhodes, P., 1968. British Medical Journal, iv, 509 (paragraph 77 and Appendix Q.

Royal College of General Practitioners, 1968. Obstetrics in general practice: report of a
Working Party. (Reports from General Practice, 9). London, Royal College of
General Practitioners (paragraphs 68, 72, 81, 143, 213-218 and 237).

Royal College of Midwives, 1968. Statement of Policy on the maternity service. London,
Royal College of Midwives, (paragraphs 205-212).

Royal College of Obstetricians and Gynaecologists, 1968. Hospital obstetrics and the
general practitioner: report of council. London, Royal College of Obstetricians and
Gynaecologists (paragraphs 72, 82, and 199-204).

Royal College of Midwives, 1966. Preparation for Parenthood: report of the Research
Committee. (Chairman: Miss A. Wood). London, Royal College of Midwives
(paragraphs 44 and 85).

Royal Commission on Local Government in England, 1966-1969, 1969. Report.
(Cmnd. 4040). London, H.M.S.O. (paragraph 11).

Royal Commission on Medical Education, 1956-1968, 1968. Report. (Chairman: Lord
Todd). (Cmnd. 3569). London, H.M.S.O. (paragraphs 15, 72, 226-230 and 236).

Scottish Health Services Council, 1965. The Staffing of the Midwifery Services in Scot-
land: report by a committee of the Council. (Chairman: Mrs. J. Wolridge-Gordon).
Edinburgh, H.M.S.O. (paragraphs 231-234).

Sluglett, J. and Walker, S., 1956. Lancet, i, 684. (paragraph 48).

Tizard, J. P. M. and Davis, J. A., 1967. Medical News Magazine: Obstetrics and
Gynaecology, Part 2, 6 (paragraph 123).

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TABLES

Page

1 Live birth rates, confinement rates and staffed beds 1955-68 (England and

Wales (paragraph 21) 67

2 Duration of stay in maternity units 1955-68 (England and Wales) (para-
graphs 22 and 124) . . . . 67

3 Percentage distribution, by days of care after delivery, of confinements in

N.H.S. Hospitals in the years 1958 and 1968 (England and Wales) (para-
graph 23) 67

4 Institutional confinement rates, 1967 and 1968 (paragraph 24) . . . . 68

5 Births, maternal mortality, perinatal mortality and institutional confine-
ments, 1955-1968 (England and Wales) (paragraph 29) 68

6 International comparison (paragraph 31) .. .. 69

7 Mid 1968 projection (with allowance for migration), showing estimates of

live births and birth rates (England and Wales) (paragraph 32) . . . . 69

8 Perinatal mortality rate per 1 ,000 total births by hospital region, 1964-1968

(paragraphs 36 and 118) 70

9 Midwives Roll, 1957-1968 (paragraph 38) 70

10 Staff (whole-time equivalent) employed at 30th September 1959-1968

(England and Wales) (paragraphs 39 and 41) 71

1 1 Division of work between the hospital and domiciliary services, 1959-1968

(England and Wales) (paragraphs 40 and 41) 72

12 Number of authorities and number of domiciliary midwives employed at

30th September 1968 (England and Wales) (paragraph 41) . . . . 73

1 3 Administrative and supervisory staff employed in the domiciliary midwifery

service at 30th September 1968 (England and Wales) (paragraph 41) . , 73

14 Age distribution of midwives practising in years 1965-1968 (paragraph 42) 73

15 Total number of general practitioners, 1967-1968 (England and Wales)

(paragraph 61) 74

16 Number of principal medical practitioners: analysis by list sizes in regions

at 1st October, 1968 (paragraph 61) . . . . . . . . . . 75

17 Maternity Medical Services (England and Wales) — Annual Summary 1968

(paragraph 64) 76

18 Percentage distribution of grades of prenatal care with mortality ratio in

the population (perinatal Mortality Survey — 1958) (paragraph 83) . . 77

19 Causes of death ascribed to pregnancy and childbirth, 1957-1967 (England

and Wales) (paragraph 84) 77

20 Consultants in obstetrics and gynaecology, 1959-1968. Analysis showing

actual numbers and an index of numbers (paragraph 93) 78

21 Ratio of maternity beds and obstetricians to population by N.H.S. hospitals

1968 (England and Wales) (paragraphs 93 and 106) 78

22 Numbers of cases of deliveries in hospital, forceps deliveries and caesarean

sections for 1958-1966 (sample figures, with estimated total number and
percentages) (paragraph 95) 79

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Page

23 N.H.S. hospitals in-patient maternity services. Antenatal, delivery and

postnatal care, 1958-1966 (paragraph 95) 80

24 Doctors in obstetrics and gynaecology at 30th September 1968. Analysis by

employing authority and grade showing number of staff and whole-time
equivalent (paragraph 100) 82-83

25 Registrars in obstetrics and gynaecology at 30th September 1968. Analysis

by number of years since first entry to the grade (paragraph 102) . . . . 84

26 Comparison of estimated numbers in training grades (bom in Great Britain
or Irish Republic) to estimated consultant vacancies (all countries of birth)

for obstetrics and gynaecology (paragraph 104) . . 85

27 Staffed maternity beds — 1967 and throughput in relation to the institutional

and hospital confinement rates (paragraph 109) 86

28 Infant and neonatal mortality rates, 1951-1967 (England and Wales)

(paragraph 117) 86

29 Domiciliary midwives: part-time workers — vacancies and wastage, 1967

(paragraph 132) 87

30 Deliveries attended by domiciliary midwives, 1 967 (paragraphs 1 32 and 133) 88

31 Cases discharged from hospital visited by domiciliary midwives, 1967

(paragraphs 132, 134, 135 and 136) 89

32 Training in domiciliary midwifery at 30th September 1967 (paragraphs

132 and 137) 90

33 Changes in deployment of midwives (paragraphs 132 and 138) . . . . 90

34 The number and distribution of general practitioner beds available for

maternity cases at 3 1st March 1968 (paragraphs 155 and 15 6) .. .. 91

35 Regional distribution of maternity hospitals with existing or possible

catchment areas (paragraphs 155 and 159) 91

36 Summary of personnel comprising the “Flying Squads” who went out in

answer to their most recent emergency calls (paragraphs 1 55 and 160) . . 92

37 Journeys incurred by emergency obstetric services. Duration of outward

journey (paragraphs 155 and 160) 92

38 Journeys incurred by emergency obstetric services. Length of outward

journey (paragraphs 155 and 160) 92

39 Calls received by emergency obstetric services in 1967 (paragraphs 155 and

160) . . . . . . . . . . . . . . . . . . . . 93

40 The employment of domiciliary midwives in hospital (paragraphs 155 and

162) . . . . . . , . . . . . . . , . . . . . 93

41 The employment of hospital midwives solely on special duties (paragraphs

155 and 163) 93

42 Number of hospitals with midwifery staff vacancies of varying degrees of

persistence at 31st March 1968 (paragraphs 155 and 165) 94

43 Summary of reasons given by hospital midwives for leaving their employ-
ment during 1967 (paragraphs 155 and 166) 94

44 Places available and taken up in midwifery training schools, 1967 (para-
graphs 155 and 167) . . . . 94

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Table 1

Live birth rates, confinement rates and staffed beds 1955-68
(England and Wales)

Year

Live birth
rate

Percentage of
total confinements

Beds allocated

In all

institutions

InNHS

hospitals

Consultant

staffed

G.P.

staffed

1955

15-0

64-3

60-2

16,913

2,670

1964

18-5

70-0

67-1

17,085

4,090

1965

18-1

72-5

69-8

17,341

4,263

1966

17-7

75-0

72-4

17,581

4,428

1967

17*2

78-9

75-4

17,890

4,668

1968

16-9

80-6

78-6

18,153

4,882

Table 2

Duration of stay in maternity units 1955-68
(England and Wales)

Year

Average length of stay for all
NHS hospitals HIPE

Average total length of stay
(antenatal and postnatal beds)

Antenatal

(days)

Postnatal

(days)

Consultant

beds

(days)

General

practitioner

beds

(days)

1955

4-7

11-0

12-1

1M

1963

4-2

7-8

9*3

8-4

1964

4-0

7-4

8-8

7*9

1965

40

7-2

8-6

7*6

1966

3-9

6-9

8-3

7*3

1967

6-8

8-1

7*0

1968

6-6

8-0

6*8

Table 3

Percentage distribution, by days of care after delivery, of confinements in
N.H.S. Hospitals in the years 1958 and 1968.

(England and Wales)

Days of
care
after
delivery

Booked

Unbooked

All

cases

1958

1968

1958

1968

1958

1968

(also cumulative)

0

0*3

0*4

3*0

1*6

0*7

0*5 (0*5)

1

0*7

2*5

9*6

11*1

1*9

3*1 (3*6)

2

1-1

10*0

10*5

23*9

2*3

10*8 (14*4)

3

0*9

7-6

7*4

14*5

1*8

8*0 (22*4)

4

0*8

4*5

4*5

6*5

1*3

4*7 (27*1)

5

1*1

5*9

4*1

5*7

1*5

5*9 (33*0)

6

2*2

9*0

4*2

6*0

2*4

8*8 (41*8)

7

4*4

14*0

4*8

6*1

4*5

13*5 (55*3)

8—10

56*2

37*6

27*6

17*2

52*4

36*3 (91*6)

11+

32*2

8*4

24*5

7*4

31*1

8*3 (99*9)

67

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Table 4

Institutional confinement rates, 1967 and 1968

Region

Number of
local
health
authority
areas

80% and
over

70% —
under 80%

60% —
under 70%

Under

60%

1967

1968

1967

1968

1967

1968

1967 1968

Newcastle

13

7

9

2

3

3

1

1 —

Leeds

10

4

6

4

3

2

1

_ — —

Sheffield

16

5

7

8

7

3

2

— — .

East Anglia

8

_

—

2

3

4

4

2 1

Metropolitan regions

46

28

33

14

11

4

2

Oxford

8

5

7

3

1

_

-

,

South Western

10

6

9

4

1

—

. , „■ ■■ ,

Wales

17

17

17

— —

— —

Birmingham

16

2

5

11

11

3

—

—

Manchester

16

5

8

8

7

3

1

Liverpool

8

5

6

2

2

1

Wessex

6

2

3

2

2

2

1

— —

174

86

110

60

51

25

12

3 1

Table 5

Births, maternal mortality, perinatal mortality and institutional confinements

1955-1968 (England and Wales)

Year

Live

birth

rate

No. of
live
births

No. of
stillbirths

Maternal

mortality

rate

including
abortions
per 1,000
total
births

Perinatal

mortality

rate

per 1,000
total
births

Percentage of
confinements

In all
institutions

In N.H.S.
hospitals

1955

15-0

667,811

15,829

0*59

37*4

64*3

60*2

1956

15-7

700,335

16,405

0*52

36*7

64*3

60*4

1957

16-1

723,381

16,615

0*45

36*2

64*3

60*6

1958

16-4

740,715

16,288

0*43

35*0

64*1

60*4

1959

16-5

748,501

15,901

0*38

34*1

64*2

60*7

1960

17-2

785,005

15,819

0*39

32*8

64*7

61*3

1961

17-6

811,281

15,727

0*33

32*2

65 *6

62*3

1962

18*0

838,736

15,464

0*35

30*8

65*9

62*8

1963

18*2

854,055

14,989

0*28

29*3

68*2

65*1

1964

18*5

875,972

14,546

0*26

28*2

70*1

67*1

1965

18*1

862,725

13,841

0*25

26*9

72*5

69*8

1966

17*7

849,823

13,243

0*26

26*3

75*0

72*4

1967

17-2

832,164

12,528

0*20

25*4

78*9

75*4

1968

16*9

819,272

11,848
—

0*24*

24*7

80*6

78*6

^Provisional

68

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Table 6

International Comparisons

Maternity
Bed Ratio
per 1,000
population

Hospital
Confinement
Rate
per cent

Birth

Rate

per 1 5 000

Average
length of
Total Stay

U.S.S.R.

1964

M

99-9

19-6

8-9 days

Czechoslovakia

1966

0-54

98-7

15-6

5-7 days

Sweden

1964

0-50

99-7

160

6-7 days

Denmark*

1964

0-14

44-0

17-6

9-9-5 days

Holland*

1962

0-10

29-0

20-9

10-12 days

Yugoslavia

1963

0-21

—

21-4

6 days

England and Wales

1966

0-45

72-2

17-7

f 8*3 days

Consultant

4

Units

7-3 days

„ G.P. Units

England and Wales

0-58

70-0

16-6

10 days

(Cranbrook

Normal stay

recommendations)

postnatal

*Does not include private institutions.

It is not possible to calculate maternity bed ratios for the U.S.A.

Table 7

Mid 1968 projection (with allowance for migration), showing estimates of live
births and birth rates.

(England and Wales)

Birth rate

per 1,000

Year

Live births

population

1969

838,000

17-1

1970

854,000

17*3

1971

867,000

17*5

1981

920,000

17*5

1991

1,029,000

18*3

2001

1,096,000

18-0

Note: Provisional birth figures for 1969 indicate that the projection for this year is an
overestimate. (The projections used were the most recent available at the time of preparation.)

69

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Table 8

Perinatal mortality rate per 1,000 total births by hospital region 1964-1968

Hospital Region

1964

1965

1967

1968

Newcastle

32

30

28-0

24*9

Leeds

30

29

27-1

26*1

Sheffield

29

27

26-1

25*4

East Anglia

25

23

22-0

21*4

North West Metropolitan

24

24

22-6

24*2

North East Metropolitan

26

25

23*7

23*8

South East Metropolitan

27

25

22*5

22*9

South West Metropolitan

26

24

23*7

22*7

Wessex

26

23

23*8

22*8

Oxford

26

22

21*8

20*6

South Western

26

25

22*0

22*3

Welsh

32

30

27*9

27*6

Birmingham

29

29

27*1

25*1

Manchester

32

31

28*3

28*6

Liverpool

31

30

29*9

27*7

Table 9

Midwives Roll 1957-1968

(< extract from Appendix B of C.M.B. Report 1967/1968 )

Year Ended
March 31st
1 .

No. on Roll
2.

Midwives
notifying their
intention to
practise
3.

1957

61,692

17,006

1958

64,722

16,706

1959

67,768

16,445

1960

71,213

16,582

1961

74,976

17,370

1962

78,725

17,950

1963

82,721

18,378

1964

61,136*

18,724

1965

65,272

19,465

1966

69,425

19,913

1967

73,639

20,011

1968

77,791

20,399

""Clearance of Roll undertaken (C.M.B, Report 1967/8).

Note: The figure in column 3 is for the 12 months ended 31st January of the year of the
report.

70

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Table 10

Staff (whole-time equivalent) employed at 30th September 1959-1968

(England and Wales)

Year

Midwives in
hospital service*

Domiciliary

midwivest

1959

f 6,942

4,820

1960

U 7,221

4,8961

1961

(7,605

5,018

1962

7,241

5,185

u

1963

7,790

5,303

1964

8,101

5,298

1965

8,601

5,298

1966

8,810

5,203

1967

9,268

5,118

1968

9,573

4,861

*This figure includes some midwives who are employed by the hospital for work on the
district.

f Administrative staff are not included in these figures.

:|: Total number of whole-time and part-time. W.T.E. not available for these years
§As at 31st December.

71

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Table 11

Division of work between the hospital and domiciliary services 1959-1968

(England and Wales)

72

Printed image digitised by the University of Southampton Library Digitisation Unit

*Non-N.H.S., many of which are maternity homes.

■(•Includes births occuring in homes for unmarried mothers, remand homes, reception centres, etc.

Table 12

Number of authorities and number of domiciliary midwives employed at 30th
September 1968.

(England and Wales)

Domiciliary Midwives

Number of
Authorities
1 .

Whole-time
equivalent of

Total
Number
of staff
6.

Whole-time

2.

Part-time

3.

Part-time

4.

All staff
5.

All authorities
Total

175

3,406

3,608

1,455

4,861

7,014

English Counties

46

1,461

2,998

1,209

2,670

4,459

English County
Boroughs

79

1,317

194

98

1,415

1,511

London Boroughs

33

431

81

39

470

512

Wales

17

197

335

109

306

532

Table 13

Administrative and supervisory staff employed in the domiciliary midwifery
service at 30th September 1968.

(England and Wales)

Whole-time equivalent of

Total num-
ber of staff

Whole-time

Part-time

Part-time

All staff

All authorities
Total

100

347

129

229

447

English Counties

11

207

77

88

218

English County
Boroughs

69

59

19

88

128

London Boroughs

16

48

21

37

64

Wales

4

33

12

16

37

Table 14

Age distribution of midwives practising in years 1965-1968

Age group

Percentage of total number practising

1967-68

1966-67

1965-66

-24

5-3

6-5

5-8

25-29

18-9

19-1

20*2

30-39

28-2

26-5

25-7

40-49

23-0

22-7

22*7

50-59

19-8

21*1

21*4

60-64

3-7

3*1

3-0

65-

1*1

1-0

M

73

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Table 15

Total number of general practitioners 1967 and 1968
(England and Wales)

1967

1968

All practitioners

21,305

21,410

Principals

20,427

20,515

Assistants

758

757

Trainees

120

138

All principals providing unrestricted services

19,830

19,951

Single-handed principals

4,646

4,512

Members of partnerships

15,184

15,439

All principals providing restricted services

597

564

Limited lists

529

499

Principals providing maternity services only

49

46

Others

19

19

74

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8

©\

VO

3

e s

S 'o

•o 2
to O
y ■**

J* m

^ H-

73 93

« us

ai

.& •!

I

iDk *1

*

s

I

j>»

1

75

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Table 17

Maternity Medical Services (England and Wales)
Annual Summary 1968

PART A. Total number of claims paid during year

General

practitioner

obstetri-

cians

Other

general

practi-

tioners

Total

1. Number of claims paid

710,712

19,053

729,765

2. Number of cases in line 1 which included a fee for an
anaesthetist

1,380

6

1,386

PART B. Analysis based on 10 per cent sample of claims paid

Services for which fees were paid

Number of cases attended by: —

General

practitioner

obstetri-

cians

Other

general

practi-

tioners

Total

1. Complete service

277,007

3,161

280,168

2. Complete ante and post-na
confinement

tal care, i.e. without

15,077

452

15,529

3. Complete ante-natal care
(see note 2)

(a) With confinement

11,613

111

11,724

(b) Without confinement

59,994

819

60,813

4. Complete post-natal care
(see note 2)

(a) With confinement

6,963

89

7,052

(b) Without confinement

11,477

218

11,695

5. Partial ante-natal care
only

(a) With confinement

2,596

112

2,708

(b) Without confinement

105,530

5,434

110,964

6. Partial post-natal care
only

(a) With confinement

3,489

21

3,510

(b) Without confinement

18,276

872

19,148

7. Partial Ante-natal and partial post-natal care

144,763

5,320

150,083

S. Other cases (except miscarriage) including
confinement only

4,155

61

4,216

9. Miscarriage

49,772

2,383

52,155

30. Total

710,712

19,053

729,765

1 1 . Number of cases included in line 10 for which the
application for services was accepted less than
6 weeks before date of confinement

9,302

239

9,541

Notes: 1 . All services for which a fee was paid during the quarter are included in part A of
this return.

2. Line 3 includes cases which covered partial post-natal care as well as complete
ante-natal care. Similarly line 4 includes cases where partial ante-natal care was
also paid for.

Printed image digitised by the University of Southampton Library Digitisation Unit

Table 18

Percentage distribution of grades of prenatal care with mortality ratio in the
population.

C Perinatal Mortality Survey — 1958)

Grade of Prenatal Care

Per cent in
Population

Mortality

Ratio

Hospital only

20-2

101

Hospital in part

28-5

107

Local health authority clinic

19-4

84

throughout or in part

General practitioner only

IM

126

General practitioner and midwife

18-7

73

Midwife only

0-5

62

None

0-6

537

No information

0-6

191

Table 19

Causes of death ascribed to pregnancy and childbirth 1957-1967

(England and Wales)

ICD No.

Cause of death

1957

1963

1964

1965

1966

1967

642

Toxaemia of pregnancy

83

43

30

38

35

43

643, 644

Antepartum haemorrhage

7

6

—

1

1

—

645

Ectopic pregnancy

22

16

21

11

17

11

646-649

Other complications of
pregnancy

12

25

20

15

15

18

651

Abortion with sepsis

33

32

29

29

29

15

650, 652

All other abortions

28

17

21

23

24

19

670

Antepartum haemorrhage
complicating delivery

21

11

7

12

12

7

671, 672

Postpartum haemorrhage

23

21

12

11

14

5

660, 673-678

Other deaths from delivery

57

33

44

44

48

35

682, 684

Puerperal phlebitis, throm-
bosis and pulmonary
embolism

33

20

22

17

11

10

640, 641, 681

Other sepsis of pregnancy,
childbirth and puerperium

19

8

10

5

9

3

685, 686

Puerperal toxaemia

5

3

4

10

3

1

680, 683,
687-689

Other complications of
puerperium

6

8

7

5

5

5

Total

349

243

227

221

223

172

Total excluding abortion

288

194

177

169

170

138

Rate per 1,000 births
including abortion

0-47

0-28

0-26

0-25

0-26

0-20

F

77

Printed image digitised by the University of Southampton Library Digitisation Unit

Table 20

Consultants in obstetrics and gynaecology 1959-1968
Analysis showing actual numbers and an index of numbers

Year

Number of
Consultants

Index of number
of Consultants

1959

439

100

1960

444

101-1

1961

460

104-8

1962

457

104-1

1963

467

106-4

1964

485

110-5

1965

513

116-9

1966

521

118-7

1967

537

122-3

1968

555

126-4

Table 21

Ratio of maternity beds and obstetricians to population by N.H.S. hospitals 1968

(England and Wales)

Estimated

population

(thousands)

Number
of staffed
consultant
maternity
beds*

Number
of G.P.
staffed
maternity
beds*

Average r
matemi
availat
million p

lumber of
ty beds
>le per
opulation

Obstetric
consultants
per million
population
(w.t.e.)*

Hospital Region

Consultant

beds

G.P. beds

Newcastle

3,092-2

1,280

244

413-9

78-9

11-4

Leeds

3,231-8

1,210

331

374-4

102-4

7-1

Sheffield

4,605-5

1,434

485

311-4

105-3

5-7

East Anglia

1,713-8

493

151

287-7

88-1

7-3

Metropolitan Regions

North West

4,192-1

2,011

35

479-7

8-3

12-0

North East

3,397-2

1,657

143

487-8

42*1

9-7

South East

3,536*0

1,363

232

385-5

65-6

9-3

South West

3,255-0

1,472

221

452-2

67-9

11-9

Oxford

1,900-6

571

344

300-4

181-0

8-4

South Western

3,092-2

773

732

250-0

236-7

7-2

Wales

2,720-0

1,065

352

391*5

129-4

9-4

Birmingham

5,084-5

1,594

599

313-5

117-8

8-4

Manchester

4,551-6

1,667

613

366-2

134-7

9-1

Liverpool

2,256-4

1,037

107

459-6

47-4

9-6

Wessex

1,964-1

526

293

267-8

149-2

7-5

^Figures relate to all hospitals (i.e. Regional Hospital Boards and Boards of Governors).

78

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79

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Table 23

N.H.S. hospitals in-patient maternity services. Antenatal, delivery and postnatal care 1958-1966

ty- • •

I

I

Printed image digitised by the University of Southampton Library Digitisation Unit

Printed image digitised by the University of Southampton Library Digitisation Unit

Table 24

Doctors in obstetrics and gynaecology at 30th September 1968
Analysis by employing authority and grade showing number of staff and whole-time equivalent

82

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999

(N (N (N

999

h fN-t

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r|- | cn^Tr-Tfr

''t I CO t-i Tt* Tf

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83

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Table 25

Registrars in obstetrics and gynaecology at 30th September 1968.
Analysis by number of years since first entry to the grade

Years since first entry to the grade

Country of birth

Total

less than 1

1 but less
than 2

2 but less
than 3

3 but less
than 4

4 years
and over

Total

407

135

116

71

37

48

Born G.B., NX, or
Republic of Ireland

159

59

38

26

20

16

Born Overseas

248

76

78

45

17

32

84

Printed image digitised by the University of Southampton Library Digitisation Unit

TABLE 26

rOM PARI SON OF ESTIMATED NUMBERS IN TRAINING GRADES <

fBORN IN GREAT

BRITAIN OR IRISH REPUBLIC) TO ESTIMATED CONSULTANT VACANCIES ( ML

COUNTRIES OF BIRTH j

i FOR OBSTETRICS AND GYNAECOLOGY

ESTIMATES BASED ON

NUMBER OF STAFF IN POST AT SEPTEMBER 1966

80-

70-

60-

50 -

40 —

30

20 -

I O-

ESTIMATE OF
AN NUAL
NUMBER OF
REGISTRARS
COMPLETING
TV/0 YEARS
IN THE
GRADE, AND
THUS
AVAILABLE
FOR

PROMOTION
TO SENIOR
REGISTRAR

ESTIMATE OF

ANNUAL

NUMBER OF

SENIOR

REGISTRARS

COMPLETING

3 YEARS IN

THE GRADE

AND THUS

AVAILABLE

FOR

CONSULTANT

POSTS

ESTIMATE OF

CONSULTANT

POSTS

AVAILABLE

ANNUALLY

J

>. EXPANSION

~\

WASTAGE

85

Printed image digitised by the University of Southampton Library Digitisation Unit

Table 27

Staffed maternity beds — 1967 and throughput in relation to the institutional
and hospital confinement rates.

Area

1

Staffed Beds
per 1,000
population
female
age 15-44

2

Staffed Beds
per 1,000
live and still
births in
NHS
hospitals
3

Throughput
(cases
treated per
available
bed per
year)

4

Live and
still births
in institu-
tions (NHS
and other)
as percentage
of total
births
5

Live and still
births in
NHS

hospitals as
percentage of
total births
6

England and Wales

2-4

35*4

35*6

77*8

75*4

Newcastle

2-5

37*9

35*2

77*5

75*4

Leeds

2-5

34-9

35-4

78*4

77*6

Sheffield

2-1

32-5

39*8

71*9

69*0

East Anglian

1-8

33*1

39*1

67*1

60*6

N.W. Met.

2-4

33*6

31*7

80*8

77*9

N.E. Met.

2-8

43*3

31*6

76*8

75*2

S.E. Met.

2-3

37*7

31*8

76*8

74*9

S.W. Met.

2-5

37*0

33*5

85*2

79*2

Oxford

2-4

32*4

41*0

80*9

77*0

South Western

2-6

37*1

35*0

80*3

78*2

Wales

2-8

37-8

34*6

86*4

85*4

Birmingham

2-1

31*8

39*8

72*2

71*5

Manchester

2-5

34*4

36*6

78*0

77*3

Liverpool

2-6

34*6

35*4

82*7

81*3

Wessex

2-1

34*5

37*7

76*5

70*0

Table 28

Infant and neonatal mortality rates 1951-1967
(England and Wales)

Year

Live birth
rates
per 1,000
population

Infant mortality rates per 1,000 live births

Total

1st day

Rest of
1st week

7 days-
4 weeks

4 weeks-
3 months

1951-1955

15*2

26*9

7*5

7*5

3*0

3*4

1956-1960

16*4

22*6

7*5

6*3

2*4

2*6

1964

18*5

19*9

7*1

4*9

1*8

2*4

1966

17*7

19*0

6*5

4*6

1*7

2*5

1967

17*2

18*3

6*3

4*4

1*8

2*4

86

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Table 29

Domiciliary midwives : part-time workers — vacancies and wastage 1967

English

County

Councils

English

County

Boroughs

London

Boroughs

Wales

England

and

Wales

Number of authorities in
survey

42

76

32

17

167

A

Part-time midwives not em-
ployed by the authority on
any other nursing duties at
30th September 1967.
Number of midwives

112

161

37

12

322

Number of authorities

27

36

14

2

79

B

Vacancies for domiciliary
midwives at 30th Septem-
ber 1967.

Whole-time equivalent of
vacancies

237

117

34

40

428

Number of authorities with
vacancies.

Total

39

34

16

10

99

All persisting for less than
3 months

3

3

2

8

Some persisting for 3-5
months

23

11

7

2

43

Some persisting for 6-1 1
months

18

11

8

4

41

Some persisting for more
than 12 months

16

13

6

10

45

C

Wastage of domiciliary mid-
wives.

Number who left during year
1967 giving reasons.

Total

432

169

65

45

711

Retirement

113

36

6

17

172

Domestic

176

64

30

16

286

Insufficient congenial work

14

2

2

3

21

Other known reasons

116

66

26

9

217

Reasons unknown

13

1

1

—

15

87

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Table 30

Deliveries attended by domiciliary midwives 1967

English

County

Councils

English

County

Boroughs

London

Boroughs

Wales

England

and

Wales

Number of authorities in
survey

42

76

32

17

167

A

Number of confinements
attended under N.H.S.
arrangements Jan-Sept.
1967.

Total

72,068

43,699

15,654

4,938

136,359

At home

71,274

43,310

15,625

4,631

134,840

In hospitals

786

212

22

304

1,324

Other

8

177

7

3

195

B

Number of domiciliary mid-
wives who delivered
patients in hospital

87

47

12

27

173

Number of authorities re-
cording such deliveries

12

4

2

4

22

C

Number of midwives who at-
tended 5 or less deliveries
Jan-Sept. 1967.

Part-time midwives not em-
ployed by the Authority
on other nursing duties

62

127

30

1

220

All others (including dis-
trict nurse/midwives etc.)

756

42

14

289

1,101

D

Deliveries attended annually
per domiciliary midwife.
Average number:

(t)23

39

38

12

27

Number of authorities re-
cording the following:
Under 20 deliveries annually

26

6

3

14

49

21-30

9

10

5

2

26

31-40

7

29

12

1

49

41-50

—

21

10

—

31

51-60

—

6

1

_

7

Over 60

—

4

1

—

5

E

Minimum number of deliver-
ies a domiciliary midwife
should attend to retain her
skills in delivery.

Number of authorities re-
plying — Total

40

69

28

15

152

Opinions given :

(15 authorities did not ans-
wer this question).

1-10 confinements annually

5

2

4

11

11-20

25

19

5

6

55

21-30

10

26

13

4

53

30-40

—

8

2

_

10

Over 40

—

16

6

1

23

(f) Based on annual rate of deliveries during Jan-Sept. 1967 and actual number of midwives
at 30th September, 1967.

88

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Table 31

Cases discharged from hospital visited by domiciliary midwives 1967

English

English

London

England

County

County

Bor-

and

Councils

Bor-

oughs

oughs

Wales

Wales

Number of authorities in Survey*

42

76

32

17

167

A

Women discharged from hospital who
received their first postnatal visit by

domiciliary midwives during three months

July-September 1967

Total numbers of women

Totals for whom days after delivery

39,173

29,456

4,816

7,141

80,586

were known:

27,944

28,731

3,810

7,141

67,626

[a) Discharged within 48 hr. after delivery

4,784

3,592

1,246

784

10,406

lb) „ „ 2-4 days,,

7,175

6,687

1,648

1,832

17,342

(c) „ „ 5-7 days „

6,999

10,209

690

2,880

20,778

(d) „ „ 8-10 „ „

8,109

7,313

210

1,356

16,988

(e) „ „ 11 or more,, „

Percentages of totals for whom days
after delivery were known:

Discharged within: —

877

930

16

289

2,112

(a) 48 hours after delivery

17

13

33

11

15

(b) 2-4 days „

26

23

43

26

26

(c) 5-7 days „

25

35

18

40

31

(d) 8-10 days „ „

29

26

6

19

25

(e) 11 or more days „

3

3

0

4

3

B

Women resident in authorities’ areas
who were delivered in hospitals and
other institutions during July-Sept.
1967 (estimated)

71,552

43,777

27,751

9,541

152,621

C

Women visited as percentages of total
delivered in hospital etc. (Total of A.
above as percentage of B.)

55

67

17

75

53

D

Estimated deliveries in hospitals etc. as
percentage of all deliveries for women
resident in areas July-Sept. 1967

75

75

84

86

77

E

Employment of midwives solely on post -

natal visits to “ early discharge " cases
Number so employed on Sept. 30th,

131

1967

20

70

28

13

Number of others who would be pre-
pared to do only this

625

167

59

216

1,067

*18 Authorities were unable to give the full breakdown (a) to (e).

89

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Table 32

Training in domiciliary midwifery at 30th September, 1967

English

County

Councils

English

County

Bor-

oughs

London

Bor-

oughs

Wales

Total

Number of authorities in survey

42

76

32

17

167

A

Authorities responsible for complete part
II training

(a) Number of responsible authorities

3

18

2

2

25

(b) Number which will arrange training
for other areas’ pupils

1

11

1

1

14

(c) Places available per year

60

411

76

56

603

(d) Number of approved midwife tea-
chers

23

195

16

17

251

B

Authorities not responsible for complete
part II training

(a) Number of authorities which accept
pupils

35

55

30

5

125

(b) Number which accept pupils from
hospitals in
(i) authority’s area

29

44

22

4

99

(ii) other areas

19

15

20

3

57

(c) Number of places provided for
pupils in

(i) authority’s area

947

1,521

573

122

3,163

(ii) other areas

296

296

332

—

924

(d) number of approved midwife tea-
chers

542

557

263

50

1,412

Table 33

Changes in deployment of midwives

{extracted from replies to question 19 in appendix E — questionnaire issued October
1967)

English

County

Councils

English

County

Bor-

oughs

London

Bor-

oughs

Wales

Total

Total number of authorities in survey

42

76

32

17

167

A

Number of authorities which reported
changes in deployment

41

38

17

11

107

B

Number which used the following
methods: —

(a) Redundancy

12

6

6

2

26

(b) Extension of home nursing duties

23

3

3

5

34

(c) Alteration of range of duties

27

20

8

6

61

(d) Other methods

23

24

9

6

62

C

Number of authorities where changes
in deployment were associated with a
higher institutional confinement rate

32

35

15

7

89

D

Number of authorities which had a
change in the range of midwifery duties
other than increase in work with
“early discharge” cases

22

29

8

8

67

90

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Table 34

The number and distribution of general practitioner beds available for maternity
cases at 31st March 1968.

Region

In same
ward as
consultant
beds

Close to
Consultant
ward

Separated

from

Consultant

ward

Completely separate
G.P. Unit

Total

Number

%

TOTAL

320

442

276

4,107

80

5,102

Newcastle

83

66

205

58

354

Leeds

30

46

33

295

82

361

Sheffield

36

79

390

77

505

East Anglia

—

16

—

144

90

160

N.W. Met.

12

36

75

48

N.E. Met.

—

22

32

102

65

156

S.E. Met.

25

10

,

218

86

253

S.W. Met,

40

21

—

152

71

213

Oxford

16

26

14

268

83

324

S. Western

48

43

17

626

85

734

Wales

—

—

20

362

95

382

Birmingham

158

43

411

67

612

Manchester

17

9

41

545

89

612

Liverpool

17

—

10

79

75

106

Wessex

8

w—

274

97

282

Table 35

Regional distribution of maternity hospitals with existing or possible catchment
areas

{extracted from replies to question 4 in Appendix G — questionnaire issued April
1968)

Region

Total number
of maternity
hospitals

Number with
catchment
areas

Number where
catchment areas
could be defined

Other

maternity

hospitals

Total

651

256

141

254

Newcastle

42

24

—

18

Leeds

41

14

27

—

Sheffield

60

10

50

—

East Anglia

24

— *

24

N.W. Met.

34

16

18

18

N.E. Met.

41

15

8

S.E. Met.

43

14

26

3

S.W. Met.

46

25

12

9

Oxford

30

—

—

30

S. Western

66

66

—

—

Wales

59

19

— -

40

Birmingham

55

—

—

55

Manchester

59

14

—

45

Liverpool

21

9

—

12

Wessex

30

30

91

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Table 36

Summary of personnel comprising the “Flying Squads” who went out in answer
to their most recent emergency calls

{extracted from replies to question 3 of Appendix A to Appendix G — questionnaire
issued April 1968 )

Consultant

58

Registrar

115

House Officer

72

Anaesthetist

49

General Practitioners

1

Midwife/nurse

146

Medical student

28

Pupil midwife

2

Table 37

Journeys incurred by emergency obstetric services

{extracted from replies to question 2 of Appendix A to Appendix G — questionnaire
issued April 1968 )

Duration of outward journey

Minutes

No. of squads recording

Average

Maximum

Under 10

12

{»

10-20

101

21-30

36

43

31-45

10

46

46-60

r 7

35

Over 60

l 7

27

Not known

29

33

Table 38

Length of outward journey

Miles

No. of squa<

is recording

Average

Maximum

Under 3

12

f

3-5

65

< 37

6-10

71

1

11-15

20

53

16-20

(

33

21-30

< 6

36

Over 30

l

13

Not known

21

23

92

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Table 39

Calls received by emergency obstetric services in 1967*

Type of case

Domiciliary

G.P. Unit

Other

Abortion

314

5

1

Antenatal

391

27

11

Delivery

840

225

8

Postnatal

895

149

38

Total

2,440

406

58

““Incomplete returns, which relate to only 175 squads.

Table 40

The employment of domiciliary midwives in hospital

{extracted from replies to question 7 in Appendix G— questionnaire issued April
1968 )

(a) The number of hospitals where domiciliary midwives undertake deliveries

(b) Number of midwives involved (whole-time equivalent)

(c) Number of cases delivered

(d) Number included in ( b ) doing work which could otherwise be done by hospital
midwives on the establishment

(e) Number included in (b) who are necessarily helping to staff hospitals

51

216

1994

65

31

Note: The majority of cases delivered (item c) were concentrated in the following regions :

Oxford 736 S.W. Met. 338 Birmingham 138

Wales 426 Manchester 280 S. Western 59

Table 41

The employment of hospital midwives solely on special duties

{extracted from replies to question 8 in Appendix G — questionnaire issued April
1968 )

Whole-time

staff

Part-time

staff

Total

Antenatal

371

267

638

Delivery

796

206

1,002

Postnatal

627

238

865

Special care baby units

380

115

495

Milk kitchens

26

24

50

Total

2,200

850

3,050

G 93

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Table 42

Number of hospitals with midwifery staff vacancies of varying degrees of
persistence at 31st March 1968.

Vacancies persisting for under 3 months
„ „ „ 3 to 6 months

„ „ „ 6 to 12 months

„ „ 12 months or more

136

103

120

185

Total number of hospitals — 365.

Table 43

Summary of reasons given by hospital midwives for leaving their employment
during 1967.

Retirement

112

Domestic Reasons

1,243

Insufficient Congenial Work

48

Other Reasons

990

Reason not known

156

Table 44

Places available and taken up in midwifery training schools — 1967

Region

Training Sch

ools

Places p

rovided

Number
accepted
for training

Part I

Part II

Com-

bined

.Pla
Part I

xs

Part II

Inta
Part I

kes

Part 11

Part I

Part II

Total E. & W.

83

116

74

5,722

4,224

1,170

857

5,811

3,780

Newcastle

5

9

4

238

174

23

53

259

145

Leeds

4

4

6

268

99

16

8

304

109

Sheffield

3

10

5

314

311

39

57

339

292

E. Anglia

2

2

1

127

76

4

4

119

48

N.W. Met.

3

5

12

708

552

56

60

661

529

N.E. Met.

9

4

8

898

472

255

86

787

346

S.E. Met.

6

7

7

553

352

225

145

550

395

S.W. Met.

11

10

4

645

454

56

40

711

352

Oxford

4

9

—

150

198

12

33

131

175

S. Western

2

4

4

271

204

214

93

380

195

Wales

5

7

3

170

132

99

59

199

113

Birmingham

5

9

8

250

212

51

60

411

306

Manchester

14

13

6

482

t485

82

100

439

J384

Liverpool

8

11

3

550

306

28

24

403

247

Wessex

2

12

3

98

197

10

35

118

144

•[includes 80 integrated courses
J includes 51 integrated courses

94

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APPENDICES

A. Health Services and Public Health Act 1968— Section 10, Midwifery

Services (paragraph 48) . 96

B. National Health Service — Maternity Medical Services (paragraph 70) . 97-98

C. General practitioner obstetric beds in a consultant unit, Oldershaw and

Brudenell 1968 — Rhodes, 1968; (paragraph 77) . . . .99-100

D. Domiciliary obstetrics in a group practice (paragraph 88) . . .100

E. Questionnaire on the domiciliary midwifery service (paragraph 131) 102-106

F. Summary of replies to questionnaire to Chairmen of Local Medical Com-

mittees (paragraphs 143-154) 107-115

G. Questionnaire to Senior Administrative Medical Officers of Regional Hos-

pital Boards (paragraphs 1 55-179) 116-120

H. Matters on which the views of the Central Midwives Board were sought and

memorandum of evidence submitted by the Board (paragraph 1 80) 121-122

I. Factors affecting the needs for maternity beds (paragraphs 188, 192-197,

and 261) 123-131

J. Factors affecting the provision of delivery beds (paragraphs 188 and 196) 132-135

95

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APPENDIX A

HEALTH SERVICES AND PUBLIC HEALTH ACT 1968

Section 10

Health Services provided by local Health
Authorities

MIDWIFERY SERVICES

Section 10 of the 1968 Act repeals Section 23 (Midwifery) of the National Health
Service Act 1946 which is replaced by the following provisions :

Section 10-(1) “It shall be the duty of every local health authority to secure,
whether by making arrangements with Boards of Governors of teaching hospitals.
Hospital Management Committees or voluntary organisations for the employ-
ment by those Boards, Committees or organisations of certified midwives or by
themselves employing such midwives, that the number of such midwives so em-
ployed who are available in the authority’s area for attendance on women in their
homes as midwives is adequate for the needs of the area and that the midwives so
available as aforesaid are enabled to render all services reasonably necessary for
the proper care of the women upon whom they so attend.

(2) A local health authority may make provision in their area in manner aforesaid
for the attendance on women, elsewhere than in their homes or in hospitals vested
in the Minister, as midwives of certified midwives so employed.

(3) A local health authority may make arrangements with a Hospital Management
Committee exercising functions with respect to the management and control of a
hospital or with a Board of Governors exercising functions with respect to the
administration of a teaching hospital for there to be made available in the hospital,
on such terms and conditions as may be agreed, the services of certified midwives
employed by the authority for the purposes of either of the two foregoing sub-
sections and may make arrangements with another local health authority for there
to be made available in that other authority’s area, on such terms and conditions
as may be agreed, the services of such midwives as aforesaid.”

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APPENDIX B

NATIONAL HEALTH SERVICE
MATERNITY MEDICAL SERVICES

1. The Minister of Health, in agreement with the representatives of the profession, has
reconsidered the conditions set out in E.C.N. 347 required by a doctor applying to the
Local Obstetric Committee for inclusion in the obstetric list, and has made certain
changes as will be seen in (i), (vi) and (vii) below. These are not however major changes
and are more in the nature of clarification. They do not apply to doctors already in-
cluded in the list. The Minister now determines for the purposes of Regulation 2(1) of
the National Health Service (General Medical and Pharmaceutical Services) Regula-
tions 1962 that on or after 1st October 1966 the applicant will be required to satisfy one
of the following conditions; he shall:

(i) have within the period of ten years previous to the date of application for
approval of his experience, held a six months’ resident appointment in an
obstetric unit in a hospital in the United Kingdom or the Republic of Ireland
or held a similar appointment in an obstetric unit in a British Armed Forces
hospital outside the United Kingdom. Such an appointment shall include:

(a) a joint post in an obstetric and gynaecological unit or a joint post in an
obstetric and paediatric unit, or

( b ) rotating internships between obstetric and gynaecological units in one or
more hospitals.

if, in the opinion of the Local Obstetric Committee, the applicant spent
sufficient time in obstetrics; or

(ii) where he has held a resident appointment as described in condition (i) above
but not within ten years of the date of application, have attended within five
years previous to the date of application a refresher course in obstetrics of not
less than one week provided under Section 48 of the National Health Service
Act, 1946, of the National Health Service (Scotland) Act, 1947 or the Health
Services Act, 1948 (Northern Ireland), by a University or Medical School in
the United Kingdom or a refresher course of similar standard approved by
such a University or School; or spent not less than two weeks working as a
resident obstetric officer in an obstetric unit in the United Kingdom under the
supervision of a consultant; or

(iii) have been within the period of two years previous to the date of application on
the obstetric list of the same or another Executive Council and at the time of
leaving it could have qualified for admission to it under (i) or (ii) above; or

(iv) have been a principal in obstetric practice in the United Kingdom involving
attendance in the five years previous to the date of application on not less than
100 maternity cases for which he has been responsible for antenatal care in all,
and supervision of labour and the puerperium in at least 50; or

(v) be at the time of application on another obstetric list in England or Wales; or

(vi) have had within the two years previous to the date of application experience in
an obstetric unit under a consultant obstetrician in a hospital in the United
Kingdom; this experience, some of which may have been gained in a resident

97

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clinical attachment in the same or another consultant obstetric unit, should
have involved regular work in the obstetric unit or units during six consecu-
tive months within the two year period and should include :

(a) not less than 20 normal deliveries, and

( b ) attendance at not less than 10 abnormal confinements, and

(c) attendance at not less than 10 antenatal and two postnatal clinics; or

(vii) have had experience which the Minister on the recommendation of a Local
Obstetric Committee and after consultation with the representative of the
profession approves as acceptable experience in the light of the above con-
ditions.

2. The chief effect of the new conditions is to include in (i) above experience gained in
hospitals in the Republic of Ireland or with the British Armed Forces; to restrict the
experience described at (iv) to that gained as a principal; and to provide at (vi), excep-
tionally, for some resident experience to count as an alternative to the more usual non-
resident experience.

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APPENDIX C

GENERAL PRACTITIONER OBSTETRIC BEDS IN A
CONSULTANT UNIT

Oldershaw and Brudenell (1968)

Oldershaw and Brudenell (1968) describe the first 500 deliveries or so supervised by
general practitioners in Consultant Obstetric Units of Dulwich and St. Giles 5 Hospitals.
The scheme was initiated following discussions at the local maternity liaison com-
mittees. Only general practitioners on the obstetric list were invited to attend; only
women with unsuitable home conditions and fulfilling the criteria for confinement in a
general practitioner maternity unit were accepted. The consultant obstetrician retained
sole responsibility for the patients ; the general practitioner working under his general
direction. Initially 80 general practitioners applied to use beds; eventually only 25
doctors in 14 practices made use of the scheme. Each general practitioner had an
honorary contract with the hospital.

Antenatal Care

The initial antenatal examination is performed by the general practitioners. Blood is
taken for routine testing and a chest X-ray is arranged. The results are entered on a
co-operation card (MCW 2 66) and bearing this card the patient attends the hospital
booking clinic. Details are entered in the hospital records. The patient then attends the
general practitioner for antenatal care until the 34th week when she returns to the hos-
pital to be seen by the consultant or his registrar and her continuing suitability for g.p.
care is confirmed.

During Labour and Puerperium

At the onset of labour the patient is admitted to hospital and the general practitioner
informed. Responsibility for the management of labour rests with the general prac-
titioner who is expected to be present at the confinement when possible. The patient is
under the general practitioner’s care during the puerperium. He is also responsible for
the care of the baby under the direction of the consultant paediatrician. The postnatal
examination is carried out by the general practitioner at his surgery.

Attendance of general practitioner at Delivery
The general practitioner was present at 175 (40 per cent) of a possible 436 deliveries,
i.e. after excluding cases previously handed over to consultant care. Doctors in partner-
ship could attend a higher percentage of deliveries than single handed ones.

Perinatal Mortality

The authors point out that a perinatal mortality rate of 12 per 1,000 for patients
under general practitioner care in the review is encouraging; Hobbs and Acheson (1966)
found the perinatal mortality rate in such cases to be as high as 82 per 1,000.

Abnormalities necessitating transfer to consultant care arose in 12 per cent of this
specially selected low risk group and transfer to hospital would have been necessary for
half as many again had they been booked for home delivery.

Rhodes (1968)

Rhodes (1968) outlines a scheme by which the St. Thomas’ Hospital Board of
Governors agreed to make available to general practitioners in the area four beds in the
Consultant Maternity Unit at Lambeth Hospital. The scheme was limited to 12 doctors

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who were offered and accepted an honorary contract with the Board of Governors. In
other organisational respects it resembled that described by Oldershaw and Brudenell
(1968).

A review following 2 years’ working shows that there were only 86 deliveries com-
pared with an expected 150. Of the 86 patients 41 were visited during the first stage of
labour by their booked doctors but 20 of those were by one doctor, who looked after 47
patients out of 86. In 9 cases there was great difficulty in contacting the doctor and in 4
others the doctor told the labour ward staff that he was not to be called further about
his patient. (The increasing use of the emergency call service makes it difficult to get in
touch with general practitioners on their days off).

Rhodes points out that general practitioners over-estimated their needs and under-
estimated their difficulties in getting to see their patients during labour and delivery.
There has, however, been inestimable value to the patients in the continuity of antenatal
care and visits to them by their doctors while in hospital. Also their postnatal care has
been so much better because of the close personal attention of jtheir own doctors. The
author stresses the need to appraise the ability and willingness of general practitioners
to attend women in labour when they know they will be cared for, in any case, by the
hospital staff.

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APPENDIX D

DOMICILIARY OBSTETRICS IN A GROUP PRACTICE

Hudson (1968) describes domiciliary obstetrics by a group of four general prac-
titioners in a review period from January 1960 to December 1966. The survey was
retrospective based on midwives records; the object was to assess the success of selection
of women for home delivery and pin-point errors of judgement. In the review period
there were 1,465 pregnancies exceeding 28 weeks gestation; 667 or 45 per cent were
initially booked for home confinement.

Of the 667 women booked for home confinement, 83 per cent were eventually
delivered at home, 12 -1 per cent developed complications in the antenatal period which
required hospital delivery and 4*1 per cent were transferred to hospital in labour. 60
primigrafidae were booked for home confinement but 40 per cent required transfer to
hospital either before or during labour. The majority of transfers in labour were due to
delay in the first and second stages or of foetal distress.

The author points out that the outstanding fact which emerged from the survey is the
high rate of transfer of primigravidae both before and during labour which indicates
that they should all be booked for confinement in specialist units. Further, the low
incidence of complications in home delivered patients and the low perinatal mortality
rates, i.e. 5*4 per 1,000 demonstrate that conscientious antenatal care and careful initial
selection of cases for place of confinement provide a high degree of safety for home
deliveries.

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APPENDIX E

QUESTIONNAIRE ON THE DOMICILIARY MIDWIFERY SERVICE

CENTRAL HEALTH SERVICES COUNCIL
STANDING MATERNITY AND MIDWIFERY ADVISORY COMMITTEE
SUB-COMMITTEE TO CONSIDER THE FUTURE OF THE DOMICILIARY MIDWIFERY SERVICE

Local Health Authority

QUESTIONNAIRE ON THE DOMICILIARY MIDWIFERY SERVICE

Employment of Midwives

1. (a) Number of domiciliary midwifery staff employed on September 30th 1967
(include those employed by voluntary organisations, H.M.C.’s or B.G.’s as on
LHS 27/9 Part A lines 1, 2 and 3).

Administrative and supervisory

Domiciliary Midwives

Whole-

time

(1)

Part-

time

(2)

Whole-
time
equiva-
lent
of (2)
(3)

Vacan-

cies

at

30.9.67

(W.T.E.)

Whole-

time

(4)

Part-

time

(5)

Whole-
time
equiva-
lent
of (5)
(6)

Vacan-

cies

at

30.9.67

(W.T.E.)

(b) Is a non-medical supervisor employed ? Yes/No0

(c) If so, is she engaged full-time on statutory supervisory duties ?

(SRO.1937 No. 398)

2. How many of the midwives shown in question 1, column (5) were
not employed by the Authority on any other nursing duties ?

3. How many domiciliary midwives deliver patients in hospital ?*

4. How many domiciliary midwives are attached to General Prac-
tices? (i.e. their allotted patients are those of the practice and
not those of the area)

5. How many domiciliary midwives are employed solely on postnatal
visits to early discharge cases ?

Yes/No0

If none,
write none

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6. If you have vacancies for domiciliary midwives (shown in question
1 ) how long have they persisted ?

3 months Yes/No0

6 months Yes/No0

12 months or more Yes/No 0

For

Official

Use

G

H

7. How many midwives have left domiciliary midwifery in 1967?
(if none, write none)

What were the main reasons given: —

(a) Retirement

(b) Domestic, e.g. marriage, pregnancy, moving home

(c) Insufficient congenial work

(d) Other (known reasons)

(e) Other (reasons not known)

(Total of (a) to (e) should equal the number who have left).

Deliveries

8. Number of confinements attended by domiciliary midwives during
the period 1st January-30th September 1967 under N.H.S.
arrangements (a) at home

(b) in hospitals*

(c) other

( d ) total

0 Delete as appropriate.

* Hospital includes consultant and G.P. beds.

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(number of
instances)

9 .

How many domiciliary midwives have attended 5 or less deliveries
during the period 1st January~30th September, 1967,

(a) Part-time midwives shown in question 2 above

( b ) All others (including district nurse/midwives, etc.)

Early Discharge Cases

10. How many women discharged from hospital received their first
postnatal visit by domiciliary midwives during the three months
July-September, 1967?

(a) discharged within 48 hours after delivery

(b)

2-4 days

99 99

(c)

5-7 „

99 99

id)

8-10 „

99 99

(e)

1 1 or more days

99 99

(f)

Total

No. of
women

For official
use

1 1 . Please estimate the number of women resident in your Authority’s
area who were delivered in hospitals* and other institutions
during July-September, 1967

Training in Domiciliary Midwifery

12. Is your Authority directly responsible for a complete Part II train-
ing of pupil midwives ? Yes/No0

IF THE ANSWER TO 12 IS “YES” PLEASE ANSWER QUESTIONS 13-15
IF THE ANSWER TO 12 IS “NO” PLEASE ANSWER QUESTIONS 16-18

13. How many pupil midwife places per year (i.e, pupils per intake

multiplied by number of intakes) do you provide ?

14. Do you arrange practical training within your area for pupils from

other areas?

15. Number of approved midwife teachers at 30th September, 1967 . .

16. Does your Authority accept Part II pupil midwives?

If “Yes”:

(a) From a hospital Part II Training School in your area . .

(b) From a hospital situated in another LHA’s area . .

Yes/No0

Yes/No0

Yes/No0

Yes/No0

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17. How many pupil midwife places per year (i.e. pupils per intake
multiplied by number of intakes) for pupils from

O) a hospital Part II Training School in your area
(b) a hospital situated in another LHA area

18. Number of approved midwife teachers at 30th September, 1967. .
General Considerations

19. Has the deployment of domiciliary midwives been changed in any

of the following ways:

(a) redundancy

(b) extension of home nursing duties of HN/DM

(c) alteration of range of duties

(d) other methods (describe)

20. Are the changes in deployment the result of or associated with a
higher institutional confinement rate

If “Yes”, describe how

21. Are there any changes in the range of midwifery duties, other than
increase in work with early discharge cases ?

If “Yes”, describe

22, What do you consider to be the minimum number of deliveries
per year ajnidwife must attend to retain her skills in delivery?

How do you arrive at this figure?

23. How many of your present domiciliary midwives other than those
shown in question 5 would be prepared to undertake only post-
natal care of mothers and babies (i.e., without attending
delivery ?

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Yes/No0

Yes/No0

Yes/No0

Yes/No0

Yes/No0

Yes/No0

Future Administration

If you have views on the form of administration of midwifery services (for example,
it has been suggested that they might be unified) the Sub-Committee would be pleased
if you would indicate them here: if you would like to see changes, perhaps you would
indicate the advantages, and disadvantages, of what you propose.

(Signed)

Medical Officer of Health.

Please return 2 copies of this questionnaire to: Ministry of Health,

Statistics and Research Division,
Room 414,

14, Russell Square,

London, W.C.l.

The third copy is for the use of the Authority. Further copies may be obtained from
the above address, to which queries should also be referred (Telephone number:
MUSeum 6811 — Extension 269).

0 Delete as appropriate.

* Hospital includes consultant and G.P. beds.

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APPENDIX F

SUMMARY OF REPLIES TO QUESTIONNAIRE TO
CHAIRMEN OF LOCAL MEDICAL COMMITTEES

FOREWORD

1. In March, 1968, a questionnaire was sent to the Chairmen of Local Medical Com-
mittees in England and Wales, asking them to express their views on the future pattern
of the midwifery service as a whole, and setting down ten headings under which they
might formulate their replies. The Chairmen were also asked to consider the possible
role of General Practitioners in co-operative pilot schemes which might be set up in
some areas.

2. The questionnaire was circulated to all 134 Local Medical Committee Chairmen,
and 77 replies were received (a 58 per cent response). The aim of the following report is to
set down the views expressed and to establish some consensus of opinion based on the
doctors’ replies.

3. It should be noted that some Chairmen expressed their personal views, some put the
questionnaire before their Committee for discussion, in some cases a working group
being set up for this purpose, while some handed the questionnaire to a doctor more
involved than themselves in obstetrics and hence better qualified to make recommenda-
tions on this matter. The result is that all views expressed are of doctors either directly
involved in, or particularly interested in, the Maternity Service.

I. THE CONTINUANCE OF DOMICILIARY MIDWIFERY

4. The majority view was that Domiciliary Midwifery should continue; 59 per cent
voted in its favour, 26 per cent felt that it would have to continue, but should be dis-
couraged; and 15 per cent felt that it should be discontinued.

5. The 59 per cent in favour emphasised the point that the patient must be allowed to
decide whether or not she wishes to have her baby at home, although there should be
certain conditions which must be satisfied before a doctor will agree to a home confine-
ment; namely, that as a safety precaution, it be established that the patient’s home is
comfortable, clean and adequately equipped, and that, as far as is possible, it be estab-
lished that no serious complication will arise in the course of the confinement. In this
case, thorough antenatal care will be necessary, with specialist consultation at least in
the early stages of the pregnancy and at 36 weeks. Some stressed that all doctors attend-
ing home confinements should be trained to the standard required for entry to the
Obstetric List, and that the midwives accompanying them should be hospital based to
ensure the maintenance of their skills. The doctor and midwife would then be able to
deal with minor abnormalities. In cases of emergency, however, the patient should be
taken by well equipped ambulance to a main hospital or, in rural districts, to a cottage
hospital where there are facilities to deal with more serious abnormalities arising during
the birth. It is appreciated that a home help service is at present provided, but some
doctors suggested that it should be extended so that such facilities might be available
for all patients having their babies at home. Some expressed the view that the present
trend towards hospital confinement is largely the result of a misleading pressure on the
public, encouraging them to believe that hospital confinement is always better. They
felt that this was not necessarily true.

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6. Various arguments were forwarded in favour of the continuance of domiciliary
midwifery. It was felt above all that it is psychologically better for a woman to have her
baby at home; the birth of a child is a family matter and should, if possible, take place
in the shelter of the home. Again, if a woman already has young children, it is better for
them that their mother is not taken from them for the period of confinement. Other
points made in this connection were that a woman is running less risk of infection if she
has her baby at home, that there is a financial saving if she does not make use of
hospital facilities and that the pressure on hospital beds is lessened if the number of
hospital confinements is reduced.

7. The 26 per cent expressing the view that domiciliary midwifery would have to con-
tinue, but should be discouraged, felt that patients who feel strongly that they would
like to have their babies at home should be allowed to do so as long as the conditions
stated in paragraph 5 above are satisfied. However, patients who have less positive
feelings on this matter should be encouraged to go into hospital for at least the period
of confinement, and criteria should be set down for compulsory admission to hospital;
e.g. in the case of a patient with a past record of difficult births. The 24 or 48 hour
hospital stay was highly recommended ; this system would enable more patients to make
use of hospital facilities, allowing them both the greater safety of a hospital confinement
and the possibility of being back at home with their family very soon after the birth of
the child. The extended use of the home help service was again mentioned in this con-
text. On the whole, doctors sharing the view that domiciliary midwifery should be
greatly reduced felt the service to be out-dated. They would prefer to see patients
admitted for delivery to the maternity wing of a regional hospital, to a general prac-
titioner maternity unit or to the delivery wing of a cottage hospital. In this case, all
midwives would be in some way hospital based, either spending part of the year work-
ing in hospital and part in the district, or visiting patients at their homes for antenatal
and postnatal care and following them into hospital for delivery.

8. 15 per cent were against the continuance of domiciliary confinements. They felt it to
be grossly out-dated and far too risky, pointing out that as the number of domiciliary
cases declines, general practitioners and district midwives lose their expertise. Such a
situation, they said, would be avoided if separate domiciliary midwifery was discon-
tinued and hospital midwifery facilities were expanded to cope with the increased
burden. A 24 or 48 hour hospital stay system was favoured by most of the doctors
holding this point of view, as was the principle of the general practitioner attending his
patients at hospital confinements so that an element of continuity and of personal care
its maintained in the service.

9. The majority view was, therefore, that domiciliary midwifery should continue. Most
favoured the increased use of the minimum hospital stay system, either for patients who
would prefer hospital confinement or for all maternity patients, and in the latter case
domiciliary service would tend to develop into a service for domiciliary antenatal and
postnatal care, the midwife working both in the district and in a hospital to maintain
her professional skills. Some doctors felt that all the midwifery services should be either
hospital or clinic based and thus the midwife engaged solely in domiciliary work should
be abolished. There was, therefore, on the one hand the demand for integration of the
maternity services, and on the other hand the demand for an increase in hospital
maternity facilities to precede the total hospitalisation of the service.

11 • arrangements for general practitioners to provide maternity

MEDICAL SERVICES TO THEIR PATIENTS IN HOSPITAL

10. Doctors agreed overwhelmingly that general practitioners should be able to pro-
vide maternity services to their patients in hospitals or maternity units. Only one of the
77 replies expressed any doubt, saying in this case that although it may be desirable for
general practitioners to provide such a service, there are insuperable administrative

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problems, for in large towns many general practitioners will have access to a relatively
small number of hospital beds. Some of the doctors expressing their views raised a
second problem, namely that if a general practitioner were to take part in a hospital
maternity scheme, he would have to cope with an increased work load and oragnisa-
tional difficulties. If the doctor is to follow his patient into hospital for her co nfin ement
he will probably be faced with clashes in his time-table and, above all, more irregular
working hours. However, such problems were not felt to be insuperable, particularly
for doctors working in group practice. . .

11, > In favour pf the principle of general practitioners providing maternity medical
services in hospitals, it was suggested that it is highly preferable for a matercpty patient
to be treated in hospital by her own general practitioner whom sheknows,and in whom
she has confidence. The general practitioner is the natural person to deal with such a
matter, and he would act as a channel of communication between patient and hospital
staff, thus helping to overcome the patient’s apprehension and to make .easier the work
of the hospital staff. The aim would be to secure continuity of treatment, the general
practitioner seeing his patient at antenatal and postnatal sessions and attending her
hospital confinement, in normal cases, to ensure the patient’s ease, and, to bring about a
reduction in the consultant’s workload so that he may attend to the more problematic
cases which are in greater need of his expert care.

12. On the point of organisation, many suggested that the general practitioner should

be integrated into the hospital maternity service to deal, howeyer, only with normal
cases and working on the understanding that if any difficulties should arise the con-
sultant obstetrician must be called in; formal limits for general practitioner care might
be set down to facilitate this. The implication was that most doctors favoured the idea
tjhat general practitioner beds be accommodated in special general practitioner units
which would be separate from, though within easy reach of, a consultant unit. 14 per
cent categorically expressed such a preference, 41 per cent implied that this would be
their choice, 33 per cent made no reference to the nature or situation of general prac-
titioner beds. 12 per cent, however, specifically recommended that the general practitioner
beds should be in the consultant unit, a general practitioner working as a member of
the hospital obstetric team with the midwives and with the consultant who wouldhave the
overall responsibility for the unit. The general practitioner might then gain a wide range
of experience, eventually being able to cope with some of the complications arising and
lessening the consultant’s workload. -s

13, However, most visualised the general practitioner working in a totally separate
pnit, and in this case he would have overall responsibility for his patients. He would
hold antenatal and postnatal sessions at a hospital, at a unit or at his surgery, attending
confinements and transferring all difficult cases to the consultant; unit, whereupon the
consultant would assume responsibility. General Practitioner units might be staffed
either by a permanent team of midwives, or by a team of hospital midwives and the
domiciliary midwives attached to the doctors using the unit. It was generally felt, that
the doctors should satisfy certain criteria to qualify for the use of hospital maternity
beds, either as for the Obstetric List or as decided by the individual hospital authority.
There should be a clearly defined on-call rota, or each doctor should make sure that he
will be able to attend his patient at her confinement. Emphasis was placed on the view
that general practitioners should be of real status in the unit, and should be remunerated
adequately, perhaps on a sessional basis. It was felt that if the unit is well enough
equipped general practitioner obstetricians will be able to cope with minor abnormali-
ties, thus relieving the consultant’s burden, and if a short-stay system is introduced,
hospital facilities will be available for a greater number of maternity cases than at
present.

14. The majority opinion favoured arrangements for general practitioners to provide
maternity medical services to their patients in hospitals, and preferably in separate

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general practitioner units. Such an arrangement, it was felt, would, be, feasible for a,
doctor in group practice who might be sufficiently involved in midwifery to make it
worthwhile gearing his practice to obstetrics. The single-handed doctor and doctors in
designated areas, however, would probably have to face organisational difficulties. The
main point in favour of a general practitioner obstetrician having hospital maternity
beds was that a continuity of treatment and a warm and relaxed atmosphere, such as is
often lost in the present consultant maternity unit, would be maintained in the service.
Or again, that the opportunity of such hospital work would attract doctors into general
practice. The important proviso made throughout was that the general practitioner
obstetrician must maintain a constantly high level of efficiency if he is to earn the
respect and trust which is essential to his being accepted as an equal by the hospital staff
and to the smooth working of the whole machine.

nr. ATTACHMENT SCHEMES WITH DOMICILIARY MIDWIVES, AND THE
EMPLOYMENT OF DOMICILIARY MIDWTVES IN HOSPITAL

15. The vast majority (97 per cent), was in favour of both attachment schemes and the
employment of domiciliary midwives in hospital. Both were seen as steps towards the
overall aim of greater continuity within the service.

16. It was felt that domiciliary midwives might be usefully attached to doctors in
general practice, working with several practices of single-handed doctors or with just
one group practice. Such a scheme would in the first place secure a greater element of
organisation in this area of the service, with practitioner and midwife working together
as a team, so providing a superior service and saving time through co-ordination. Tltd
domiciliary midwife, in this case, would continue in her present role, visiting heir
patients at home throughout and after pregnancy, but in addition she would attend’
general practitioner antenatal and postnatal sessions, also home confinements with the
general practitioner as a member of a team.

17. Many based their replies on the assumption that general practitioners, in a re-

organised service, would provide maternity medical services to their patients in prac-
titioner hospital beds, and thus felt that the domiciliary midwife should be employed in
hospital to work hand in hand with the general practitioner, attending with him any
remaining home confinements, antenatal and postnatal sessions at a clinic or maternity
unit, and caring for patients dining a short hospital confinement, (24 or 48 hour stay),
after which the patient would return home to continue under the midwife’s care. It
would be essential for the smooth running of such a system that all domiciliary mid*
wives working in hospital should enjoy the same status as their fellow midwives
employed permanently there. This, it seems, has proved a problem for those already
involved in such a scheme: relations between domiciliary and hospital midwives have
become so Unsatisfactory that the situation has become quite untenable. ' * ‘ -

18. In this connection, a large number, (45 per cent), while agreeing that the present
situation is probably best met by measures as suggested above, felt that the role of the
domiciliary midwife might,, in a reorganised service, be abandoned, and that all midi
wives might be hospital based. The system would then be that some hospital midwives
would be attached to a general practitioner providing maternity medical services in that
hospital, working with him in the hospital, attending general practitioner clinics and
coping with any remaining domiciliary work: or, that midwives would spend some time
working in hospital and some in the district, thus following a system of rotation. In
both cases the midwife is better equipped to cope with the ever decreasing number of,
home confinements she has to attend, her skills being better maintained than the present
system in most cases allows. A more even distribution of midwives would be attained,
correcting the present imbalance whereby there are over-worked hospital midwives and
underworked domiciliary midwives, and any conflict between hospital and domiciliary
midwives would be avoided. Those who considered that all confinements should take

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P hospital felt that the aspects of district work which do not call for midwifery
skills should be carried out by other workers. The domiciliary midwife concerned only
with domiciliary work would no longer exist, and all midwives would come under one

authority, probably that of the Regional Hospital Board — not that of the Local Health
Authority.

19. Hie views expressed in favour of attachment schemes and the employment of
domiciliary midwives in hospitals varied in intensity, but all seemed to feel that changes
along these lines would make for an improved service. There would be a continuity of
care such as is not generally found under the present system: this would be psychologi-
cally better for the patient, and would avoid duplication of service and clashes in terms
of clinical advice.

20. However, mention should be made of the disadvantages, stated by the few, of
such schemes. In connection with attachment schemes, it was felt that there might be
geographical problems, but organisational and personal problems were foreseen in
connection with the employment of midwives in hospital. Domiciliary midwives work
to a fonnal on and off duty system, but if they were to give continuous care to general
practitioner patients their hours would be irregular and doubtless many domiciliary
midwives who have families of their own would be discouraged from the service. The
remedy heie would be the use of an on-call rota, in which case the aim of continuity
would be forfeited.

IV. RELATIONSHIP BETWEEN GENERAL PRACTITIONER OBSTETRICIAN AND
CONSULTANT OBSTETRICIAN, INCLUDING LIAISON ARRANGEMENTS

21. It was unanimously agreed that a good relationship should be established between
the general practitioner obstetrician and the consultant obstetrician, basically fostered
through mutual respect and trust. Some felt that this develops naturally, particularly
when the general practitioner and the consultant have joint hospital use. This matter
will depend upon their personalities, and it was mentioned that cases have arisen in
which the consultant was not always willing to co-operate with the general practitioner
who provides maternity medical services in hospital.

22. However, some felt it to be possible that this relationship might be fostered through
formal liaison. Local Medical Committees might take on this function, or a satisfactory
situation might be achieved by setting up obstetric liaison committees made up of the
general practitioners, the consultant, the medical officer of health and the midwives
working together. In the first place the committee should meet to discuss the setting up
of any new obstetrics scheme, whether this be for the general practitioner to provide
maternity medical services in beds allotted to him from the consultant unit, or for him
to provide a similar service in his own hospital unit. There might then be periodic
meetings to discuss difficulties. Another suggestion was that regular seminars might be
held for those involved in hospital obstetrics: through these the general practitioner
and the consultant might establish common ground which would be the basis of a
sound relationship.

23. On the point of formal organisation, doctors’ comments varied according to the
type of service they visualised for the future. In the case of general practitioners providing
a domiciliary obstetric service it was felt that the consultant obstetrician should see the
patient in the early stages of pregnancy, and at 36 weeks. The patient might attend the
consultant’s clinic, or the consultant might see the patient under some domiciliary
visiting scheme. A general practitioner working in a separate general practitioners’ unit
would have overall responsibility for his patients, but they would see the consultant at
least twice during the course of pregnancy to ensure that abnormalities in delivery
were unlikely and that the general practitioner would be well able to conduct the
confinement. The general practitioner would hand all difficult cases to the consultant
obstetrician and the patient would then become the consultant’s responsibility. The

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consultant would have overall responsibility for patients using general practitioner
beds within his own unit, and in this case the general practitioner would work as a
member of the hospital obstetric team, and would enjoy the status of a respected
member of that team.

24. Hence, opinion was in favour of a close relationship between the general prac-
titioner obstetrician and the consultant obstetrician, and largely it was implied that the
nature of this relationship and the means chosen to achieve it should be decided by the
people involved: no hard rules could be set down, but the means should be suited to the
individual situation and the individual personality. The possibility of a division of
overall responsibility between consultants and general practitioner obstetricians in a
combined maternity unit was not mentioned.

V. THE ADMINISTRATION OF MATERNITY DEPARTMENTS ADMITTING
PATIENTS UNDER THE CARE OF THEIR GENERAL PRACTITIONERS — BOOKING
POLICY, ON-CALL ROTA, EMERGENCY PROCEDURES, EQUIPMENT ETC.

25. The most important point made in connection with the administration of such
maternity departments was that all arrangements should be designed to suit local con-
ditions — any general plan would be impractical. However, doctors made many helpful
suggestions under this heading.

26. It was felt that if a general practitioner obstetric unit is in operation it must be seen,
(a) as an integral part of general practice, and (b) be fully staffed with a sister, nurses,
permanent midwives and attached midwives. The administration of such a unit might
be decided by a fully representative committee, including nursing staff. Alternatively,
this might be left in the hands of the general practitioners and the consultant, a medical
advisory committee with general practitioner representation or of an obstetric liaison
committee. Several doctors stated that the Central Midwives Board’s concern with the
training of midwives should not influence the administration of schemes of this kind.

27. A few doctors suggested that, according to the facilities available, each participat-
ing general practitioner obstetrician should be allowed a certain number of deliveries
for which he would be responsible unless, in case of emergency, the patient was handed
into the specialist’s care. The number of beds allotted to any one general practitioner,
whether in a separate unit or in the consultant unit, might be related to the number of
patients on his list who are of child-bearing age.

28. Booking was thought best organised according to local conditions, giving priority
not only to abnormal cases, but also to cases in which there is social difficulty. The
domiciliary midwife would inspect home conditions and decide whether or not ad-
mission on social grounds is desirable. The general practitioner might deal with book-
ings for his own maternity beds, taking applications from his patients or alternatively,
this might be left to the hospital maternity departments who would notify the general
practitioner as soon as his patient’s booking was confirmed.

29. Most felt that an on-call rota for general practitioner obstetricians should be drawn
up by mutual agreement, as at present in group practices, and there should also be an
arrangement by which the consultant may be called in emergency cases. An alternative
suggestion, however, was that there should be no on-call rota, but that the general
practitioner should be called when his patient is in labour— if he cannot attend, the
hospital would take full responsibility. Above all good communications and organisa-
tion would be essential,

30. It was unanimously stated that general practitioner units should be as fully equipped
as possible in each case, and should be within easy reach of a specialist unit to which
serious cases might be transferred. The equipment, to be provided by the hospital,
would include at least, for example, general anaesthetic apparatus and infant resusci-
tation equipment: equipment should be adequate for all but theatre work.

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VI. THE ROLE OF GENERAL PRACTITIONER CLINICAL ASSISTANTS

31 . Clinical assistantships were seen largely as the means by which general practitioners
might gain obstetric experience in preparation for work in a general practitioner
obstetric unit, or as a form of refresher course for doctors still operating a domiciliary
maternity service. The former might be long term appointments of say 1 or 2 years, with
general practitioners working under the consultant obstetrician and so Tea ming to deal
with minor abnormalities arising during confinement. The latter would be short term
appointments, perhaps in the form of relief for the house surgeon. Alternatively,
clinical assistants might work largely in antenatal clinics. Two doctors thought that
general practitioners providing maternity medical services in hospital should be
clinical assistants, their status never rising above this.

32. Such clinical assistantships were thought valuable in that they might be educational
appointments, but they would have a two way benefit. Assistants would lessen the work
load of the permanent hospital staff, though they should never be used to cover hospital
staffing deficiencies. They might, according to the system under which they were
appointed, act as a liaison between consultant and general practitioner units and might
keep consultants in touch with the problems of general practice.

33. It was thought essential that the post of clinical assistant should be formally
appointed and that their work and ability should be adequately remunerated: also that
the clinical assistants’ legal position should be clearly defined so as to avoid any prob-
lems arising out of split responsibility.

34. All the doctors expressing their views for this report felt general practitioner
clinical assistantships to be valuable and desirable. However, present conditions in
general practice make it difficult for doctors to take such appointments, so that at the
moment schemes under which general practitioner obstetricians may use hospital
maternity beds were seen as a more realistic proposition.

vn. THE OBSTETRIC LIST

35. Most doctors, (95 per cent), commented upon the obstetric list, but they were very
divided in their opinions.

36. The largest group, (45 per cent), while agreeing that some sort of obstetric list is
necessary, thought that the criteria for admission should be amended. Criteria might be
set down in each area or there might be a national policy on this matter: these views
were equally favoured, but in all cases emphasis should be placed on making the
obstetric list a true reflexion of a doctor’s current ability — it could be stated that
doctors must complete a certain minimum number of maternity cases per annum if they
are to qualify for, or remain on, the list, also that they must attend regular post-
graduate courses at prescribed intervals. Other suggestions were that all general prac-
titioners qualifying in the first place for admission should hold the D.R.C.O.G. or
should have had some practical hospital experience in obstetrics. In a co-ordinated
service the list should be restricted to those willing to satisfy criteria in antenatal care,
attendance at delivery, adequate postnatal care and general practitioner obstetrician
refresher courses.

37. 26 per cent were quite satisfied with the present system and would wish it to con-
tinue as a means by which doctors skilledm obstetrics may be identified as such.

38. 24 per cent, however, felt the obstetric list to be an outdated formality. They thought
a good reputation the best indication of a doctor’s skills in obstetrics and that all
general practitioners trained in obstetrics should be capable of giving maternity services
as they are capable of giving’other services.

39. It was accepted, therefore, by 71 per cent that there must be some way in which a
general practitioner obstetrician may be identified as such, and this becomes more

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essential as the number of home confinements falls, for one must be able to recognise a
doctor who has maintained his skills. Finally, it was hoped that in a unified service it
will be possible for one of a group of doctors to take on all the obstetric work, devoting
a considerable amount of time to this and maintaining his skills at the highest possible
level.

vm. TRAINING AND MAINTENANCE OF SKILLS

40. Everyone stressed the importance of this matter. It is obviously essential that
general practitioners providing maternity medical services for their patients in hospital
beds should be well trained and should maintain their skills, but this is equally im-
portant for general practitioners providing an obstetric service within the normal course
of his practice — for it is his task to spot any abnormal pregnancies at any early stage so
that these may be dealt with as soon as possible.

41. Repeatedly doctors, in expressing their views upon this matter, referred to the
report, Obstetrics in General Practice, issued by the Royal College of Practitioners in
May, 1968. Since all the views expressed are embraced by the Report, it is necessary to
do no more than refer to paragraphs 64 to 83 (inclusive) of the above mentioned docu-
ment.

IX. SPECIAL PROBLEMS IN RURAL AREAS — PATIENT TRANSPORT

PROBLEMS IN GENERAL

42. Many doctors felt themselves unqualified to make comments under this heading.
45 per cent, however, made valuable suggestions. Perhaps the most outstanding point
made was that in rural areas antenatal care must be of a particularly high standard to
ensure, as far as is possible, that all abnormal cases are admitted to hospital well before
the period of confinement, the aim being to avoid domiciliary emergency, or grave
emergency in small local hospital units where staff and equipment are inadequate to
cope with the situation. It was felt, further, that patients from rural areas should be
given priority in the use of hospital beds. Any trend towards total centralization is
dangerous in that rural patients’ access to hospital facilities becomes more and more
remote.

43. Suggested immediate measures to lessen problems experienced in rural areas in-
cluded a prompt ambulance service, well equipped ambulances in which the doctor and
midwife could accompany the patient to hospital, flying squads and the provision of
transport for patients to attend clinics.

44. Another idea was that domiciliary cases in each rural area might be dealt with by a
special general practitioner employed for a limited time, perhaps immediately after he
has attended a postgraduate course in obstetrics. This system would provide a good
training ground for doctors wishing to work in obstetrics, and supplementary payment
might act as an inducement. An important point was that there will be problems in
rural areas until organised locum schemes are in operation. A general practitioner
cannot satisfactorily maintain his skills in obstetrics if he is unable to attend refresher
courses, and it is vital for a safe and well run service that the members of the obstetric
team have thorough and current experience.

X. PLACE OF THE GENERAL PRACTITIONER OBSTETRICIAN IN A

UNIFIED MATERNITY SERVICE

45. Some doctors made the point that discussion about the future of the Midwifery
Service cannot exist in isolation. These changes must be seen in the context of the over-
all changes which are to be made in administration of the National Health Service.

46. However, for opinions upon the place of the general practitioner obstetrician in a
unified service, reference should be made to the comments under headings I-VIII as set
out above. Repetition would be pointless, but, in brief, it was agreed that the general

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practitioner would play an important part in any unified maternity service. He would
liaise between hospital and midwife, and hospital and patient, he would provide an in-
valuable personal service and would play a part in lessening manpower problems.
Some saw the general practitioner working in a general practitioner maternity unit in
which he would have total responsibility, others saw him working as a team member in
a specialist maternity unit : or again, he might, within the hospital, be restricted to ante-
natal and postnatal clinic work.

XI. PILOT SCHEMES

47. Very little attention was given to the matter of pilot schemes. It was simp ly ex-
pressed that if a unified service is to be considered, such schemes will be essential in
varying types of areas.

XIL GENERAL REMARKS

48. The problem to be faced in this Report is that many of the views expressed are
ideals rather than practical suggestions; there is much conflict between what is desirable
and what is organisationally possible. There would be, for instance, great admini-
strative problems if, as was suggested, midwives were both hospital based and attached
to doctors in general practice. Also, it would be difficult to achieve both the aim of only
well qualified general practitioners working in obstetrics, and the aim of continuity of
care within the maternity service. Inevitably, some general practitioners will not be
highly skilled in obstetrics, either because they prefer to devote themselves to other
aspects of their work or because they are unable to find time to gain the necessary
experience or to attend the necessary training courses.

49. As some doctors suggested, the concept of the general practitioner providing
maternity medical services to his patients in hospital or on a highly organised scale in
the patient’s home, is really only tenable if doctors are working in group practices.
This would introduce a note of specialisation into general practice, one doctor devoting
much of his time to the maternity patients of the whole group of which he would form a
part. He would attend them from the early stages of pregnancy, would conduct the
confinement in normal cases and would supervise postnatal care, thus achieving a
continuity within the service without involving himself in administrative and organisa-
tional problems.

Xffl. STATISTICAL SUMMARY

Questionnaires circulated — 134,

Replies received by 30th October— 77.

I. The Continuance of Domiciliary Midwifery. 59 per cent in favour. 26 per cent felt
that it must continue but should be discouraged. 15 per cent totally against.

II. Arrangements for General Practitioners to Provide Maternity Medical Services to
Their Patients in Hospital. 99 per cent in favour, 1 per cent against. The ideal up-
held, but practical problems.

III. Attachment Schemes with Domiciliary Midwives, and the Employment of Domi-
ciliary Midwives in Hospital. 97 per cent in favour. 45 per cent in favour of all
domiciliary midwives being hospital based. Organisational problems.

VII. The Obstetric List. 95 per cent dealt with this: 24 per cent felt it to be outdated;
45 per cent in favour, but felt the criteria for admission should be reviewed ; 26 per
cent satisfied with the’preSent system.

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APPENDIX G

QUESTIONNAIRE TO SENIOR ADMINISTRATIVE MEDICAL
OFFICERS OF REGIONAL HOSPITAL BOARDS

CENTRAL HEALTH SERVICES COUNCIL
STANDING MATERNITY AND MIDWIFERY ADVISORY COMMITTEE
SUB -COMMITTEE TO CONSIDER THE FUTURE OF THE DOMICILIARY MIDWIFERY SERVICE

Region

1 . Number of General Practitioner beds available for maternity cases :

(a) in same ward as Consultant beds . .

( b ) in hospital and close to Consultant ward . .

(c) within hospital curtilage but separated from Consultant
Ward

(d) in completely separate (G.P.) unit

( e ) Total

2. List of areas or H.M.C.’s where requests for hospital maternity beds are not satis-
fied. Please tick columns 2 or 3 to show grounds on which additional beds would be
needed to meet all requests in the area and columns 4 to 7 to show facilities which
would be insufficient for this purpose. If there are no such areas please enter NIL.

Area

(or H.M.C.)

Additional beds
would be needed

Facilities which would be
insufficient

To meet
requests of
priority

To meet
other

Ante-natal

Delivery

suite

Lying-in

Other

(1)

groups

requests

beds

beds

beds

facilities

(2)

(3)

(4)

(5)

(6)

(7)

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Q *

(a) Have you experienced difficulty in staffing existing mater-
nity beds ? Yes/No

( b ) If Yes, please state reasons.

4. Catchment areas.

(a) How many maternity hospitals* have definite catchment

areas

(h) Would it be feasible to define catchment areas for the re- '
maining hospitals ? Yes/No

5. Obstetric flying squads.

(«) Number of flying squads based in the region. (Please

complete a separate appendix A for each flying squad) . .

(b) On the basis of your experience what do you consider
should be the medical and nursing staff for a flying squad?

(c) General comments (e.g. difficulties of maintaining the
service).

6. Hospital midwifery districts.

Please state which hospitals* provide a domiciliary midwifery service, and the
number of separate domiciliary staff (whole-time equivalent) they employ.

7. Local authority domiciliary midwives working in hospitals.

(a) In how many hospitals* do domiciliary midwives under-

take deliveries

(b) How many domiciliary midwives (whole-time equivalent)
are involved?

(c) How many cases were delivered in hospital by domiciliary
midwives during 1967 (if known) ?

id) How many included in (b) are doing work which could
otherwise be done by hospital midwives on the establish-
ment?

(e) How many included in (b) are necessarily helping to staff
hospitals ?

if) Names and addresses of hospitals included in (a):

8. How many hospital midwives0
supervisory staff) are employed

(excluding administrative and
solely f on the following:

W.T.

Staff

P.T.

Staff

f (does not include
rotating duties)

(a)

(b)

(c)
id)
(e)

Antenatal

Delivery

Postnatal

Special care baby units
Milk kitchens .. .

excluding pupil midwives.

includes hospitals with either consultant or G.P. maternity beds.

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* <s

9. Is there a trend towards specialization within midwifery. If so, please specify (e.g
Antenatal, delivery suite work) indicating in which hospitals* particular trends are
evident :

10. Has the pattern of work of hospital midwives 0 changed?:

(a) as the result of the increase in the number of hospital con-
finements Yes/No

( b ) for other reasons (please specify) :

1 1 . Vacancies for Hospital midwives0 (all grades).

(a) Numbers of vacancies (whole-time equivalent) at 31st

March, 1968

( b ) Number of hospitals which had vacancies at 31st March,

1968 which had persisted for:

(i) under 3 months

(ii) 3 months and under 6 months

(iii) 6 months and under 12 months

(iv) 12 months or more

(v) Total number of hospitals with vacancies . , . . _______

1 2. How many midwives0 are known to have left hospital midwifery

during 1967

excluding pupil midwives.

includes hospitals with either consultant or G.P. maternity beds.

13. What were the main reasons given for leaving:

(a) Retirement . . . .

(b) Domestic, e.g. marriage, pregnancy, moving home . .

(c) Insufficient congenial work

(d) Other reasons j

(e) Reason not known

(f) Total (as at item 12, above)

14. Training of Midwives.

Please state the number of midwifery training schools in the Region:

(a) Parti j“

(b) Part II

( c ) Combined

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15. (a) How many pupil midwifejplaces did they provide in 1967

Number of Places . .

Number of' Intakes . .

(b) What was the total number of pupil midwives'accepted for training in 1967

(a) Parti .. .. .. .. .. ' *

(6) Part II . . .. ..

16. (a) Has the setting up of additional midwifery training facilities
(Part I and/or Part II) in the Region been contemplated in
the past 2 years? .. Yes/No

(b) If Yes, with what objectives? . ,

Parti

Part II

17. (a) Have formal steps to achieve this been taken . . . . Yes/No

(6) If Yes, have the objectives stated in answer to' 3(b) been achieved ?

(c) If they have not, please indicate for what reasons.

18. [Supervision of mfdwives.

To what extent does the supervision provided under Section 31 of the Midwives
Act, 1951 (read swith earlier Acts, including Section 8 of the Midwives Act, 1902)
afford assistance to hospitals as employers of midwives (please comment).

19. Early discharge.

(a) Does planned early discharge under the present arrangements lead to any
administrative difficulties (Please state).

(b) What is the reaction of hospital midwives to 48 hour discharge

20. Maternity Liaison Committee.

(a) Ho^itiatiy exist in your region? .. .. j

(b) How often do they meet ?

(c) How effective are they? .. .. .. ..

21. S.A.M.O.’s views on the future pattern of services and administration.

fH In putting forward suggestions on the possible future pattern of maternity services
it would be helpful if some estimate could be given of the number of hospital mid-
wives likely to be needed, and some comments made on arrangements for their
training appropriate to the pattern of service which you envisage.

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APPENDIX A

Please coraplete one form for each obstetric flying squad.

1. Name and address of hospital where flying squad is based :

2. What is the estimated average duration and distance of journeys in answer to calls
(i.e. outward journey only), and the maximum range of such journeys:

(a) average miles minutes.

( b ) maximum miles minutes.

3. Which of the following actually went on the last visit (please tick as appropriate):

4. What transport was used for the last visit

5. Total number of calls answered during 1967, and details (if known)

Domiciliary

G.P. Unit

p

Other

Total

(a) Abortion

( b ) Antenatal complications

(c) Delivery

(d) Postnatal complications

(e) Total

. .

. , j

t Please give grand total in any case, and complete the table as far as possible from such
information as is readily available.

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APPENDIX H

MATTERS ONjWHICH THE VIEWS OF THE CENTRAL
MIDWIVES BOARD WERE SOUGHT

1. The possibility of integration of the present hospital and local authority maternity
services under the administration of hospital authorities or, if and when these emerge,
area health boards.

2. In the event of such integration, the provision of domiciliary midwifery to be under-
taken by hospital-based midwives, possibly under a system of rotation.

3. The encouragement of combined general practitioner/consultant obstetric units to
permit common use of maternity beds, delivery suites and other hospital facilities. (The
possible effects of such combination on the arrangements for training midwives is a
matter of particular interest to the Sub-Committee).

4. The means by which standards of professional skills might be maintained if mid-
wives were allowed to continue to conduct confinements solely in the domiciliary field,
having regard to the falling domiciliary confinement rate.

5. The form of supervision of midwifery which would be appropriate to an integrated
service.

6. The possibility that intending midwives who wished to undertake work other than
the conduct of confinements might be enabled to specialise at some point during their
training.

7. Under the present tripartite system, so long as it prevails, the encouragement of
closer co-operation between hospitals and local authorities, with local authority mid-
wives freely available to work in hospitals where this would be mutually advantageous.

CENTRAL MIDWIVES BOARD

Memorandum of Evidence to the Sub-Committee on the Future of
Domiciliary Midwifery and Bed Needs

1. The Board fully agree that there should be integration of the present hospital and
domiciliary midwifery services.

In many areas considerable adjustment of organisation and staffing would have to be
made to the hospital authorities as at present constituted to enable them to undertake
the administration of an integrated service.

2. In areas where integration is possible, the domiciliary service could be administered
from the hospital. Where midwives are employed full-time in urban areas some rotation
of duties may be possible although not all midwives will wish to take part in this. In the
Board’s view difficulties in areas where there are a number of district nurse midwives are
likely to be insuperable.

The Board do not think that 100 per cent hospital delivery over the country as a
whole will ever be achieved and are satisfied that in all areas there will be a continuing
need for midwives to be available for domiciliary deliveries. The proportion will vary
from area to area, 184,000 women were delivered in their own homes in 1967 and the
domiciliary midwifery service also undertook the postnatal care of over half the
hospital deliveries (314,000 early discharges in 1967).

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The Board are of the opinion also that with the increasing attachment of midwives to
group general medical practice and the continued use of general practitioner obstetric
units the overall standard of midwifery will be better and the administration will be
simpler and more efficient if certain midwives are geared to the general practitioner
service rather than to the hospital service.

3. The Board allow the use of general practitioner beds in the training of Part II pupils,
but they have hot yet been accepted for Part I midwifery training. With the introduction
of integrated training and with closer integration of general practitioner beds into con-
sultant units this difference may disappear, and indeed the Board would welcome
suitable general practitioner obstetrician participation in midwifery training, subject to
detailed approval and control by the Board.

4. The present statutory provisions for the Board to make rules about refresher courses
(Midwives Act 1951 Section 4(i)(d)) would enable suitable courses to be devised and
made compulsory.

5. The Board have urged a revision of the statutory provisions for local supervision of
midwives (Midwives Act 1951 Section 17(1)). In the Board’s view supervision (involving
as it does midwives practising in nursing homes, religious organisations, prisons, the
defence services and private domiciliary practice, as well as the national health service)
should be separated from provision of the service. Indeed the failure of some local
health authorities to undertake supervision, as distinct from organising their own
domiciliary service, has been a source of weakness for some time.

6. In the Board’s view a midwife needs to understand the total care of the patient in
order to be able to carry out any part of that care and the Board have no intention of
introducing a second grade of midwife which would in any case be outside the terms of
the present Midwives Act.

7. Co-ordination is already taking place in many areas where domiciliary midwives are
available and are willing to work in hospitals under the terms of the Health Services and
Public Health Act, 1968.

The Board suggest the following interim measures :

(a) the appointment of hospital obstetric and paediatric consultants to local
health authority staffs with advisory responsibilities for a defined area;

( b ) the appointment of local authority supervisors of midwives to hospital staffs
with liaision responsibilities for a defined area;

(c) the definition of the function of the health centre or group practice to supple-
ment or replace local authority and hospital clinics in the maternity service;

(d) the areas of responsibility of hospital for maternity care should be reviewed
and redefined.

6th March, 1969.

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APPENDIX I

FACTORS AFFECTING THE NEEDS FOR MATERNITY BEDS

1 . The main factors which have been considered as influencing maternity bed needs are
the number of live and still births, the percentage of these bom in N.H.S. hospitals, the
postnatal length of stay, the percentage occupancy and the percentage of beds used for
antenatal care,

2. Past trends in these factors are presented graphically as a help towards jud g ing the
values which the factors might take at future dates, but projectio ns of births are given
to 1981,

3. A table of bed needs is given for the period 1969-1981 based on the birth projections
and using different assumptions about the values of the other principal factors. This
table can be used in two ways— either as a guide to the number of beds needed to
achieve a given percentage (80, 90, 100) of births in N.H.S. hospitals or, given the
number of beds likely to be provided at future dates, to estimate the proportion of
births which can take place in hospital on various assumptions about postnatal length
of stay, bed occupancy and the proportion of beds that may be required for antenatal
care.

4. Graph I shows the number of live and still births from 1953 to 1968, with estimated
numbers for 1969 to 1981, based on the mid-1968 Government Actuary projections of
live births, with a small correction to include still births. Births reached a maximum of
nearly 900,000 in 1964, but have since decreased. Future estimates indicate that, by
1972, the number will have reached the 1964 peak and will continue to increase, but at a
slower rate after 1973. The total number of births (domiciliary and hospital) per avail-
able bed is shown as an indication of the pressure on the hospital maternity services,
and has been decreasing since 1964.

5. Pressure on the inpatient maternity services appears to be closely correlated with
throughput— the higher the pressure, the higher the throughout— as is shown in a
regional comparison in Table 4. If future provision of maternity beds rises at about the
same percentage rate as births (for example, from about 23,000 beds in 1969 to about
25,000 in 1981) then pressure on the hospitals will remain static at the rather low 1968
level and a special stimulus may be needed if the proportion of births in hospital is to
continue to rise as it has done recently.

6. Graph II shows that the percentage of births taking place in N.H.S. hospitals has
increased rapidly since 1960 to nearly 80 per cent in 1968. (A small percentage, about
3 per cent, of births take place in private nursing homes). The main change in length of
stay has been in the postnatal stay (Graph III) which declined from about 11 days in
1955 to under 7 days in 1968, whereas the antenatal stay has remained at about 4 days.
Bed occupancy (Graph II) which in 1957 and 1963 exceeded 82 per cent was at 74 per
cent in 1968. The decline in occupancy since 1963 seems to be associated mainly with
the decline in the birth rate. Graph IV shows that the drop in percentage bed occupancy
since 1964 has occurred in both consultant obstetric and g.p. maternity units, but that
g.p. maternity units always have a lower per cent occupancy than consultant obstetric
presumably associated with the small size of the g.p. units. The marked increase in the
proportion of g.p. maternity units is shown and if this increase continues, overall bed
occupancy may tend to be depressed. A lower postnatal stay will also tend to lower bed
occupancy since the interval between occupation remains static (at about 2 days) and
the higher number of spells of bed occupation in, say, a year will require a higher pro-
portion of the year for tumround of beds.

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7. Graph HI shows the increase in the proportion of beds used for antenatal care, which
may be a spell of care alone or the period prior to delivery. This is mainly a reflection of
the fall in postnatal compared with the comparative stability of antenatal stay. The
numbers receiving antenatal inpatient care has risen at about the same rate as the
numbers receiving postnatal care (by 44 per cent compared with 42 per cent, between
1958 and 19 66).

8. The actual numbers of beds allocated, available and occupied daily is shown in
Graph Y for 1953 to 1968. The slight difference between allocated and available beds
(2 per cent) is due to beds temporarily out of use for redecoration, staff shortages etc.
The actual number of beds occupied has remained fairly constant since 1964.

9. Table 5 is the main table of bed needs. The estimates of the average number of beds
available daily are based on the projections of births in Table 2 and on the following
ranges of values:

(a) per cent of births in hospital: 80, 90, 100;

(b) postnatal length of stay: 7, 6, 5 days;

(c) per cent occupancy : 75, 65 ;

(d) per cent beds occupied for antenatal care: 30, 25.

No correction has been made for multiple births in order to leave a margin for
transferred cases, and readmissions, especially important with regard to the trend
towards earlier discharge. The full range of values is given in each table, although some
combinations of figures are unlikely, i.e. 100 per cent hospital births in 1969. The
situation in 1968 is shown in Table 1, when the proportion of beds used for antenatal
care was probably about 27-5 per cent. It may be advisable to think in terms of a pro-
portion of 30 per cent in, say, 1981, and a bed occupancy of not more than 80 per cent.

10. As an example of the use of Table 5, a postnatal stay of 6 days in 1981, with 30 per
cent of beds allowed for antenatal care, an occupancy of 75 per cent, and a proportion
of births in hospital of 90 per cent, would require about 26,000 beds available daily,
compared with a provision of about 24,000 beds available daily in 1969. Further values
may be obtained by interpolation, and using the basic data from the previous example,
but increasing bed occupancy to 80 per cent would give an estimate of 24,500 beds in
1981 compared with 22,500 in 1969.

11. Table 3 shows the percentage distribution of maternity cases by the number of
days’ stay after delivery for the half years from 1964 to the first half of 1968. These dis-
tributions correspond to postnatal stays of about 6^-7^ days. About 14 per cent were
discharged within 48 hours of delivery in 1968. A possible distribution for 6 days is
indicated in the table.

Table 1

Present situation

Average number of beds available daily
Per cent of beds used for antenatal care
Postnatal stay (stays)

Per cent occupancy

Per cent of births in N.H.S. hospitals

(*) Estimate H.I.P.E.

(t) Provisional.

1968 1969

22,800 23 , 300 ( 1 )

27 * 5 (*)

6 - 6 (*)

74

79

124

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Table 2

Number of births in N.H.S. hospitals according to assumptions about
the proportion of births in hospitals

Per cent of births in N.H.S. hospitals

100%

90%

80%

Number of births (thousands) in N.H.S.

1969

850

765

680

hospitals

1970

866

779

693

1971

878

790

702

1981

927

834

742

Note: Pr ovisional birth figures for 1969 indicate that the projection for this year is an over-
estimate (The projections used were the most recent available at the time of preparation).

Table 3

H.I.P.E. Maternity Cases — Duration of stay after delivery.
Percentage distribution of cases by number of days stay after delivery.

Length
of stay

1964

1965

1966

1967

1968

Possible

distribu-

(days)

1st

2nd

1st

2nd

1st

2nd

1st

2nd

1st

2nd

tion

All

half

half

half

half

half

half

half

half

half

half

0-2

9

10

11

12

12

13

14

14

14

15

18

3-4

7

8

8

10

10

11

11

12

12

13

15

5-6

10

10

12

12

13

13

13

13

14

15

19

7-8

30

30

29

29

29

29

28

28

28

27

24

9-10

33

32

30

28

27

25

25

24

23

22

17

11 +

11

10

10

9

9

9

9

9

9

8

7

Mean

stay

74

7-2

6-9

6-8

6-6

60

Table 4

To show the high correlation between pressure and throughput per
available bed by region for 1968

Region

Pressure(*)

Throughput(f)

Ranking

Pressure

Throughput

East Anglia

45-5

28*9

1

8

Sheffield

43-9

31-6

2

3

Birmingham

424

31*9

3

1

Wessex

40-2

300

4

4

Oxford

39-3

31*7

5

2

Manchester

36-5

29-5

6

7

Leeds

36-5

29*2

7

6

Liverpool

35-6

29*7

8

5

Metropolitan

33-5

26*6

9

11

• Southwestern

32*9

27*7

10

10

Newcastle

32*8

26*2

11

12

Wales

31*5

27*8

12

9

(*) All births per available bed.

(t) Hospital births per available bed.

125

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Table 5

Estimates of maternity bed requirements (average number available daily)
based on various assumptions

Postnatal stay 7 days

Per cent beds used for

antenatal care 25 %

30%

Present occupancy 75 %

85%

75%

85%

Per cent N.H.S.

hospital confinement 80% 90% 100%

80% 90% 100%

80% 90% 100%

80% 90% 100%

Year

Beds 1969 23-2 26-1 29-0

(thousands) 1970 23-6 26*6 29-5

1971 24-0 27-0 29-9

1981 25-3 28*5 31*6

20-4 23*0 25-6
20-8 23*4 26*0
21*1 23*8 26-4
22-3 25*1 27-9

24-8 27*9 31*0
25*3 28-5 31*6
25*6 28*9 32*1
27*1 30*5 33*9

21*9 24*6 27*4
22*3 25*1 27*9
22*6 25*5 28*3
23*9 26*9 29*9

Postnatal stay

6 days

Per cent beds used for

antenatal care 25 %

30%

Per cent occupancy 75 %

85%

75%

85%

Per cent N.H.S.

hospital confinement 80% 90% 100%

80% 90% 100%

80% 90% 100%

80% 90% 100%

Year

Beds 1969 19*9 22*3 24*8

(thousands) 1970 20*2 22*8 25*3

1971 20*5 23*1 25*7

1981 21*7 24*4 27*1

17*5 19*7 21*9
17*9 20*1 22*3
18*1 20*4 22*6
19*1 21*5 23*9

21*3 23*9 26*6
21*7 24*4 27*1
22-0 24*8 27*5
23*2 26*1 29*0

18*8 21 *1 23*5
19*1 21*5 23*9
19*4 21*8 24*3
20*5 23*1 25*6

Post natal stay 5 days

Per cent bed used for

antenatal care 25 %

30%

Per cent occupancy 75 %

85%

75%

85%

Per cent N.H.S.

hospital confinement 80 % 90 % 100 %

80% 90% 100%

80% 90% 100%

80% 90% 100%

Year

Beds 1969 16*6 18*6 20*7

(thousands) 1970 16*9 19*0 21*1

1971 17*1 19*3 21*4

1981 18*1 20*3 22*6

14*6 16-4 18*3
14*9 16*7 18*6
15*1 17-0 18*9
15*9 17*9 19*9

17*7 20*0 22*2
18*1 20*3 22 *6
18*3 20*6 22*9
19*4 21*8 24*2

15*7 17*6 19*6
15*9 17*9 19*9
16*2 18*2 20*2
17*1 19*2 21*4

126

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THE NUMBER OF LIVE AND STILLBIRTHS IN 1953 - 1968. WITH ESTIMATED UNTiL 198U PRESSURE ON HOSPITALS
(NUMBER OF LIVE AND STILLBIRTHS PER BED AVAILABLE DAILY) IN ENGLAND AND WALES.

s — s

127

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TIME — YEARS

THE PERCENTAGE OF BIRTHS IN N.H-S. H OSPITALS . AN D TH E PERCENTAGE OF AVAILABLE 8EDS OCCUPIED

FOR 1 9 53 — i 9 68 IN ENGLAND AND WALE S

39V1N30U 3d

128

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TIME - YEARS

THE MEAN LENGTH OF STAY PER SPELL FOR ANTENATAL AND POSTNATAL CARE, AND THE PERCENTAGE OF BEDS USED
FOR ANTENATAL CARE IN N.H.S. HOSPITALS IN ENGLAND AND WALES i955-|9b8 .

3MVD 1V1VN31NV
H03 Q3Sn SQ38 30 3DVlN3D*i3d

o

tr>

q

K>

c-

1 — i — i — i — r — | — r — r

i i | - i

lA

C7*

129

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PERCENTAGE OF iEDS USED FOR ANTENATAL CARE

T HE PERCENTAGE OF AVAILABLE BEDS OCCUPIED IN CONSULTANT OBSTETRIC AND C-P. MATERNITY UNITS AND THE
PERCENTAGE OF G. P. BEDS TO MATERNITY BEDS IN N.H.S. HOSPITALS IN ENGLAND AND WALES 1955 - !Qfe8

o

130

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MATERNITY &EDS

THE AVERAGE NUMfegft Of MATERNITY BEDS ALLOCATED AVAILABLE AND OCCUPIED DAILY IN ENGLAND

AND WALES iQ53 ~ 1968

131

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OCCUPIED

APPENDIX J

FACTORS AFFECTING THE PROVISION OF DELIVERY BEDS

1. To estimate the number of delivery beds needed, births are divided into three broad
categories, namely, inductions, non-inductions and caesarian sections, and separate
estimates made for the first two groups ; the third is regarded as placing no burden on
the delivery suite.

2. The Hospital In-patient Enquiry (1958 to 1966) shows that between 4 and 5 per cent
of hospital deliveries are by caesarian section, and that the proportion of induced
deliveries had increased steadily by about 1 per cent per annum to nearly 18 per cent in
1966. Table 1 shows the number of births in each group for birth rates ranging from 15
to 22 per 1,000 in a population of 200,000, with 100 per cent hospital confinement
assuming that 20 per cent are induced, 5 per cent are by caesarian section and the
remaining 75 per cent non-induced.

3. To estimate the number of delivery beds required for non-induced cases, two
measures are required, namely, the average arrival rate of patients to the suite and the
average time spent there. The technique is based on queueing theory and so takes into
account the fact that in practice patients arrive at random and spend varying periods in
the delivery suite. This method was first used by Thompson(t) etc. in the U.S.A., and
also applied by the Department on a limited scale. In those papers the actual findings
confirmed the theoretical results, but in the present study various models are presented
only.

4. The procedure demonstrates for what proportion of the time the hospital can expect
to treat simultaneously 0, 1, 2 etc. patients and can be applied to a combined suite,
where the patient is allocated to one bed throughout the delivery or one in which
separate 1st and 2nd stage rooms are provided and the patient is transferred. The
present exercise is li m ited to a large unit with about 100 maternity beds, but can readily
be extended to any unit.

5. The average arrival rate is derived from the number of births accommodated in the
unit, which in turn is dependent on the policy concerning various factors.

Table 1 shows the average hourly arrival rate for the peak month (March) when
statistics show 10 per cent more births occur than the average for the year, in total and
in hospital.

6. The average stay in the suite depends basically on the duration of labour, but allow-
ance must also be made at the first stage for false labour for some cases, and in all cases
at the second stage for a period after delivery, when the patient receives intensive care
and observation before transfer to the lying-in beds, and also for a short interval for
room preparation between patients. In addition, patients delivered at night may not be
transferred to the ward until morning, to avoid disturbing other patients and if porters
are not available.

7. Table 2 shows the mean duration of the first and second stages of labour for primi-
parae, multiparae and all types of patients, based on the first Perinatal Mortality Survey
of 1958, the small standard errors indicating the accuracy of the results. The longer
duration of labour for primiparae is demonstrated and about 37 per cent of mothers in
the survey were included in this group; by 1967, 42 per cent of hospital births were to
primiparae, but this difference would not affect this exercise significantly. Also the 1958

132

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survey was based on both hospital and domiciliary confinements and currently nearly
80 per cent of all births are in hospital compared to just over 60 per cent in the survey.
More advanced techniques now used in hospital (and not possible at home) may have
tended to reduce the duration of labour.

8. To allow a reasonable margin for these factors, average total stays of 16 or 18 hours
were chosen, for the present calculations with average stays in the second stage of two
or four hours, and Table 3 shows for an average arrival rate of 0-3 cases per hour, the
corresponding distributions and hence the bed needs of the unit.

9. The combined suite is rarely unused, and requires 13 beds, if cases stay on average for
16 hours (or 14 beds, for 18 hours) to cope with the peak demand, but full use of the
suite is rare, as shown by the low percentages corresponding to 10 or more patients.
Alternatively, if separate rooms are used for the two stages, 12 beds are needed in the
first stage, for a stay of 14 hours, and four or six beds in the second stage for stays of
two or four hours. The second stage beds remain occupied for at least one-third of the
time. Although the combined suite requires fewer beds than the other type, each bed
must be as elaborately equipped as in the second stage suite, and so the slight saving in
numbers may not represent a true economy.

10. Table 4 provides further estimates of delivery bed needs for various average stays,
and arrival rates, corresponding to 3,000 to 4,400 births in the population of 200, 000
and in each example the maximum bed need is given, corresponding to the final value in
the percentage distribution, thus accommodating the peak demand for beds. 4,400
births annually require 18 combined suite beds, with an average stay of 18 hours, or 15
first stage beds, and seven second stage beds, with average stays of 14 and four hours
respectively.

11. Induced deliveries can be planned to some extent but it is usual to arrange such
cases in batches, rather than in a continuous flow, as delivery beds become available.
The interval between the commencement of induction and onset of labour may vary
between one and 24 hours, with an average of about 10-12 hours. Table 5 presents
estimates of induced delivery bed needs, assuming one group of patients consisting of
the same number every two or every three days, and annual numbers of cases varying
between 600 and 880, corresponding to birth rates of 15 to 22 per thousand. As for
non-induced cases, the maximum provision is provided in each example. For a birth
rate of 22 per thousand, 8 beds are needed for a group every three days, and 5 for a
group every two days. When a case experiences a short period of induction and labour,
a bed in this area would be available to cope with any surplus from the main sector,
for example, a case in false labour.

12. Examples of overall delivery bed needs induced and non-induced are shown in
Table 6 for average stays of 16 or 18 hours (for non-induced cases) by type cf suite, and
the full range of birth rates considered. The maximum requirement, for 4,400 births
and average stay of 18 hours, would be 26 combined suite beds, or 30 beds in a suite
with separate provision at the first and second stages.

13. For each estimate, the maximum number of delivery beds has been allowed, as no
alternative provision is suitable and inadequate arrangements in this highly specialised
area could limit further extension of the hospital maternity service.

(t) J. B. Thompson and others.

The application of Queueing Theory to the usage pattern of a delivery suite. Y ale
Studies of Hospital Function and Design 1. 1960.

133

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Table 1

Assumed number of births for a population of 200,000 served by a single
maternity unit, by type of delivery, with estimated peak arrival rate per hour

Birth
rate per
1,000

Annual number
of births
(100%)

Type of delivery

Average arrival rate
per hour in peak month,
for non-induced cases

Induced

(20%)

Caesarian

(5%)

Non-

induced

(75%)

15

3,000

600

150

2,250

0-28

16

3,200

640

160

2,400

0-30

17

3,400

680

170

2,550

0-32

18

3,600

720

180

2,700

0*34

19

3,800

760

190

2,850

0*36

20

4,000

800

200

3,000

0*38

21

4,200

840

210

3,150

0*40

22

4,400

880

220

3,300

0*41

Table 2

1958 Perinatal Survey: Duration of labour by stage and parity

1st stage Mean (hours)

Standard error

All

Primiparae

Mult]

tparae

120

008

16-5

017

9*4

0*08

2nd Stage Mean (hours)

Standard error

0-70

0 005

1*09

0*01

0*47

0*005

Number in 1958 Survey

16,400

6,100

10,300

Table 3

Percentage distribution of time that patients are expected to be in labour suites,

based on various assumptions

2nd stage Combined suite or 1st stage

Average stay in stage (hours) 2 4 14 16 18

Average arrival rate (hourly) 0-3 0-3 0*3 0-3 0-3

Number of patients Percentage of time “n” patients are expected to be in

n suite simultaneously

0

54*9

301

1*5

0*8

0*4

1

32*9

36*1

6*3

4*0

2*4

2

9*9

21*7

13*2

9*5

6*6

3

2*0

8*7

18*5

15*2

11-8

4

0*3

2*6

19*4

18*2

16*0

5

0

0*6

16-3

17*5

17*3

6

100*0

0*1

11*4

140

15*6

7

0

6*9

9*6

12*0

8

99*9

3*6

5*8

8*1

9

1*7

3*1

4-8

10

0*7

1*5

2*6

11

0*3

0*6

1*3

12

0*1

0*2

0*6

13

0

0*1

0*2

14

99*9

0

0*1

15

0

100*0

99*8

134

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Table 4

Delievery bed needs, excluding induction, at maximum level, by type of
suite and annual number of births

Average stay in stage (hours)

2nd stage
2 4

Combined suite or 1st stage
14 16 18

Number of non-induced births
annually

Number of delivery beds required

2,250

4

6

12

13

14

2,400

4

6

12

13

14

2,550

4

6

13

14

15

2,700

5

6

13

14

15

2,850

5

7

14

15

16

3,000

5

7

14

15

17

3,150

5

7

14

16

17

3,300

5

7

15

16

18

Table 5

Induced delivery bed needs, assuming one group every 2 or 3 days

Number of births
induced annually

Number of induced delivery
beds required for

1 group every

1 group every

3 days

2 days

600

5

4

640

6

4

680

6

4

720

6

4

760

7

5

800

7

5

840

7

5

880

8

5

Table 6

Examples of total delivery bed needs by type of suite, assuming average stay
of 16 or 18 hours for non-induced cases, and an induced group every 3 days

Number of delivery beds needed for

Annual

number

of

births

3.000

3.200

3.400
3,600
3,800

4.000

4.200

4.400

Combined Suite
(Stay=16hours)

Separate 1st and 2nd
stages

(1st stage stay== 14 hours
2nd stage stay= 2 hours)

Combined Suite
(Stay =18 hours)

Separate 1st and
2nd stages
(1st stage stay=
14 hours 2nd stage
stay— 4 hour)

18

21

19

23

19

22

20

24

20

23

21

25

20

24

21

25

22

26

23

28

22

26

24

28

23

26

24

28

24

28

26

30

Printed in England for Her Majesty’s Stationery Office by McCo
HM 3718 Dd, 500470 K 84 5/70 McC 3309.

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e & Co. Ltd., London

DEPARTMENT OF HEALTH AND SOCIAL SECURITY

WELSH OFFICE

Central Health Services Council

STANDING MATERNITY AND MIDWIFERY
ADVISORY COMMITTEE

Domiciliary Midwifery
and Maternity Bed Needs

Report of the Sub-Committee

LONDON

HER MAJESTY’S STATIONERY OFFICE

1970

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Chairman

Sir John Peel, K.C.V.O., F.R.C.S., P.R.C.O.G.*

Members

H. G. E. Arthure Esq., C.B.E., M.D., F.R.C.S., F.R.C.O.G.

Chairman of Central Midwives Board.

T. R. Bryant Esq., O.B.E., M.B., B.Ch., J.P.

General Practitioner, Tredegar, Monmouthshire.

Miss W. Frost, S.R.N., S.C.M., H.V. Cert., Q.N.

Chief Nursing Officer, Bedfordshire County Council.

Mrs. J. M. Goodman, S.R.N., S.C.M., M.T.D., Q.N.

President of Royal College of Midwives.

Professor T. N. A. Jeffcoate, M.D., F.R.C.S. (Edin.), P.R.C.O.G.*

Professor of Obstetrics and Gynaecology, The University, Liverpool.

J. Leiper Esq., M.B.E., T.D., M.B., Ch.B., D.P.H.

Medical Officer of Health, Cumberland.

Professor S. Shone, O.B.E., M.D., F.R.C.P.

Senior Administrative Medical Officer, Sheffield Regional Hospital
Board.

* Sir John Peel was President of the Royal College of Obstetricians and Gynae-
cologists until 27 September 1969 when he was succeeded by Professor Jeffcoate.

DOMICILIARY MIDWIFERY AND MATERNITY BED NEEDS

CORRECTION

Page 11, PARAGRAPH 41, LINE 3
For “decreased” Read “increased”

Department of Health and Social Security
June , 1970

LONDON: HER MAJESTY’S STATIONERY OFFICE: 1970

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CONTENTS

Page

Chapter I Preface 1

II Introduction 2-4

III Background Information and Statistics . . . 5-10

IY Maternity Services Provided by Midwives . .11-15

V Maternity Medical Services Provided by General

Practitioners 16-21

VI Maternity Services Provided by Hospital

Authorities 22-26

VII The Care of the Baby Before and After Delivery . 27-29

VIII Evidence 30-50

Medical Officers of Health ...... 30

Chairmen of Local Medical Committees ... 33

Senior Administrative Medical Officers ... 35

Central Midwives Board . . . . . 41

Statistical Papers 42

Report of Council on Hospital Obstetrics and the General
Practitioner (Royal College of Obstetricians and Gynae-
cologists) ........ 44

Statement of Policy on the Maternity Service (The Royal
College of Midwives) 45

Report of a Working Party on Obstetrics in General
Practice (Royal College of General Practitioners) . 46

“The Non-Medical Supervisor of Midwives” — paper pub-
lished by the Association of Supervisors of Midwives . 48

First Report of the Joint Working Party on the Organisa-
tion of Medical Work in Hospitals .... 48

Report of the Royal Commission on Medical Education

1965-1968 49

Report by a Committee of the Scottish Health Services
Council — The Staffing of the Midwifery Services in
Scotland 50

IX Discussion 51-59

Medical and Midwifery Maternity Services . . . 51

Bed Needs ........ 56

Postnatal care 58

Supervision .59

Mi

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X Conclusions and Recommendations .... 60-62

Interim Recommendations 60

Midwifery Services 60

Bed needs ........ 61

The Obstetric Team . . . . . . 61

General 62

REFERENCES 63-64

TABLES 1-44 65-93

APPENDICES A-J 94-134

iv

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